Considering psychotherapy can be a big decision. It involves a significant investment of time, energy, potentially money, and trusting another human being with some of your most personal thoughts, feelings and experiences.

As in previous articles, it is difficult to fully separate out the right type of therapist for a particular client from the right type of therapy. Whilst both factors are seen as important to different degrees in getting a good outcome from psychotherapy, it is an area of significant debate in healthcare research.

That being said, there appears to be a clear area of consensus: that the matching of client, therapist and therapy is frequently the most important factor in psychotherapy being effective and useful. Trying to get this matching right is ultimately the focus of this piece.

Perhaps a good place to start is to consider what sort of psychotherapy you’re looking for. Has anyone ever helped you to understand what your options are and what they should be? Have you ever been given a choice of therapy? You may find it helpful to read more about some of the core well-established therapeutic approaches:

• Cognitive Behavioural Therapy
• Psychodynamic Psychotherapy
• Cognitive Analytic Therapy
• Person-Centred or ‘humanistic’ psychotherapy
• Family and Systemic Therapy

You may have a good idea of the type of psychotherapy you’re looking for already, perhaps based on previous experiences of therapy, or your own reading and research. It might seem like an unhelpfully obvious thing to state, but the way a therapist will approach you, listen to you, ask you questions, and respond when you’re struggling, will be shaped as much by their training and therapeutic allegiances as perhaps their own personality. Arguably the two things aren’t so separate.

Before booking an appointment, it can be helpful to ask a therapist about their background, training and experience in psychotherapy and how this influences the way they work with their clients.

As multiple forms of ‘psychotherapy’ exist, many different professional groups are able to complete basic training in psychotherapy and call themselves a ‘psychotherapist’. Perhaps surprisingly, ‘Psychotherapist’ is not a protected legal title. Different types of psychotherapist require differing levels of academic qualification, specialist training, clinical experience and supervision in order to register with an accredited professional body. Ensuring your therapist is accredited with a professional organisation provides you with some assurances that they are trained to a minimum standard and that they are professionally and legally accountable to a regulated organisation.

A good rule-of-thumb when shortlisting potential therapists, is to be wary of professionals who provide very long lists of areas of expertise in either problem-type or therapy-type. Being willing to work with a vast array of different problems and experiences is not the same as being highly trained or experienced in a particular field. If you are seeking help for a specific challenge or difficulty, consider whether you want to see someone with the training and experience to call themselves a specialist in that area, or whether you simply need someone who will not judge you, who will not give advice, and is willing to listen. The experience of each therapy is very different.

Many therapists will recommend an initial phone conversation, perhaps around 15 minutes long. This should be both free and non-obligatory (i.e. is not contingent on you booking an appointment), and provides you with an opportunity to ask any questions you might have, in addition to giving you an early sense of what it feels like talking to this person, and whether it would be useful to meet for an assessment.

The assessment is also an opportunity for you to get a sense of whether you can work with a particular professional. Although the assessment process is often structured very differently to therapy, we usually ask our clients to spend some time thinking about how they found the experience afterward before considering arranging a therapy appointment. Did you feel listened to? Supported? Safe? Accepted?

Another useful recommendation is to have a brief review of the therapy relationship several sessions in. We usually check-in with our clients around the 4th session – does it feel like we’re on-track? How are you finding the sessions? What is it like working together?

Considering your own identity and diversity can be helpful here too. For instance, would it be more or less difficult for you to work with a therapist who was much older or younger than you? Could your therapy experience be influenced by the therapist’s gender? Is having a therapist with knowledge of your own cultural background important? Part of considering a potential therapist is about which of these areas you and a therapist can work through, which differences may be strengths, and which may require a closer matching.

When thinking about your approach to seeking therapy, it can also be worth considering your own experiences of past relationships, particularly with people who have been in ‘supportive’ or ‘helping’ roles, particularly parents, teachers, colleagues, and partners.

How easy do you find it asking for help? Is there anything that happens when you are struggling or in need that you think could happen with a therapist?

Are you someone who downplays problems in order to feel ‘ok’? Or might you be someone who has been let down a lot and doesn’t want to get their hopes up?

We are all needy individuals who have experienced challenge and difficulty as part of growing up, and our experiences of being in need and of being helped (or not) will also influence how well things go when we seek out potential therapists.

There is no exact science that can definitively link you to the best possible therapist for your unique circumstances, and indeed it may take several enquiries until you find someone you feel you can work with. It is important to use information to be empowered by choice rather than limited by options. When people do not have access to choice, there is a danger that clients begin to tell themselves that they cannot be helped, or that they are somehow the obstacle to change. Often, the reality is that clients have never truly been given options around who they see and how they work together with someone. Many years of psychotherapy research into the matching of therapy and therapist ultimately reach the same consensus: when people are supported to get the matching right, they generally achieve their goals in psychotherapy.

Psychotherapy is a process that seeks to improve our lives through increasing our capacity for understanding and change, particularly in the areas we find difficult or distressing.

That being said, once we begin to explore the detail of psychotherapy with greater scrutiny, ‘what it is’ becomes a much more difficult question to answer.

The field of psychotherapy is an extremely broad one. The list of individual distinct psychotherapies on Wikipedia for instance, totals 170 at the time of writing. That is supposedly 170 different approaches to understanding and improving human experiences in the name of psychotherapy. Is it possible to adequately define something that has so many different forms? Surely it would be simplistic and worrying to suggest so many different approaches can somehow at their core be united, or the same?

When we begin to explore the vast array of names and ‘brands’ of different psychotherapies, we discover that in reality there is a cluster of validated, well researched psychotherapy approaches with protected titles and training routes, each with their own governing body that is responsible for maintaining the standards of psychotherapy training and the conduct of their registered practising therapists.

Across these approaches there will be similarities and differences in how interactions are structured, how frequently sessions are held and for how long, and arguably most importantly – the approach of the therapist toward you and their underpinning ideas about human experience and change.

In the UK the dominant psychotherapy approaches have been:

• Psychoanalytic and Psychodynamic therapies: These approaches focus on understanding and changing our experiences by discovering the underpinning drives, meanings and motivations that are not always readily conscious to us. A key way this is explored is through examining what happens in relationships, particularly between therapist and client, the client’s relationship with themselves, and in the client’s everyday life.

• Cognitive Behaviour Therapy or ‘CBT’: The philosophy of CBT is that the way we experience our emotional problems and difficulties is largely explained by what we cognitively learn from our early experiences, and from how human beings have evolved to respond when they are feeling in danger or become distressed. By understanding the way we think and the relationship we have with our feelings and actions in greater detail, CBT aims to help us change experiences we find difficult or distressing through developing new patterns of thoughts and behaviour.

• Family and Systemic Therapy: Family and systemic therapy aims to help people in close relationships to better understand and support one another. This includes couples and families in addition to interactions in workplaces and large organisations. It provides an opportunity to understand and explore patterns in relationships that might be difficult, understand each individual person’s experiences, needs and views, and to develop potential solutions to relational problems.

• Humanistic Therapies: The humanistic approach is concerned with people’s capacity to make choices and develop their potential. Philosophers such as Sartre, Buber and Kierkegaard were key influencers on early humanistic therapies. The most prominent form of humanistic therapy is sometimes called ‘person-centred’ or ‘client-centred therapy’. This approach developed by the late Carl Rogers is the basis of much of what we call counselling generally today. Gestalt and Existentialist therapies are also often included within the humanistic tradition, and are arguably more rare in current practice, although many therapists are familiar with their values and ideas.

• Integrative Therapies: Many psychotherapists use several approaches in their work, and integrate different ways of working according to what their client’s need. Like psychotherapy generally, there are different theories and frameworks to help therapists consider which approaches can work well together, and how and when to consider this for each client.

Even amongst (and within) these core therapeutic traditions, there lies a world of debate around which psychotherapy is most effective, for whom, and when. This includes the questions of whether different psychotherapies work preferentially for different people – depending on their individual characteristics and experiences; or whether the effectiveness of all psychotherapies is largely based on common shared factors – particularly the quality of relationship between client and therapist.

With so much difference and so many plausible ways of developing and evaluating evidence, it can often be difficult to describe psychotherapy in any meaningful detail unless you’re referring to a specific ‘type’ of therapy.

The majority of the 170 or so therapies referenced earlier have been developed and redeveloped from the 5 key areas above, often with the aim of being more effective, briefer, cheaper, or more accessible. As the field of psychotherapy grows and each approach strives to show how it is different to the rest, the risk of both over-simplification and confusion of what psychotherapy is grows with it.

This is one reason why any referral to psychotherapy should always begin with a process of assessment. A good assessment aims to provide the client with an understanding of what’s on offer from the therapist and informed choices around potential suitable alternatives, including how they can be accessed.

Perhaps a useful way of getting a sense of what psychotherapy is, is through listening to what clients report as being important to them in therapy, and what research suggests effective therapists do:

Time

Therapy requires and is concerned with many forms of time. It requires making a stable commitment to yourself, usually for 50-60 minutes every 1-2 weeks for a period of time. Rather than attend for one session and leave transformed or ‘cured’, we know the reality is that we all live in time, and so we have to make sense of ourselves and change in time. Psychotherapy is a process. Sometimes it might be a relatively short one, perhaps a few weeks, whereas for other people they may choose to work with a therapist over several months or even years. Some clients may see the same therapist at different junctures throughout their lives, or work with several different therapists in discrete pieces of therapy.

Whatever form of time therapy work takes, it is often the period that occurs after the therapy has ended which is the most important for the client. Will the therapy somehow live on? Will anything be different afterward? how will our minds reach for the therapy in difficult moments when we no longer have the physical hour and the time of the attentive therapist that existed in our week?

Witnessing

Therapy is the experience of another human being being with you, and bearing witness to your experiences in an open and valuable way.

We often disregard a lot of our inner experience as unimportant: that advert on the television that made us feel like crying – it was stupid; feeling irritated by your sister’s lateness – it’s just a quirk; always using the same parking space at the supermarket – it’s convenient. As a result, some of the most important topics we may need to explore become confined to our mental scrap heap: how you struggle to cope with feeling vulnerable; how you’re always left feeling you make more of an effort in your relationships; how routine comforts you because it reminds you of your father. Whereas we repeatedly tell ourselves these inner experiences don’t deserve any attention, our therapists in comparison value them.

That is not to say a therapist will see every utterance you make as having some kind of latent special meaning, they are simply curious and willing to hear. The curiosity of someone else’s mind gives us the time, space and confidence to become more curious of our own. Everything has the potential to be important and is allowed a space to be heard.

Therapy is a space where, within the limits of confidentiality, we can say pretty much anything we want without being judged or censored. We don’t need to protect our therapists from our internal worlds, impress them or be fearful of their judgement, they are here to hear us, and they are able to bear us.

Perspective

Spending time with a therapist involves the experience of a certain kind of perspective. All people are inherently complex and conflicted because we are all the result of a long and relatively helpless period of infancy where we are solely dependent on others to care for us and keep us safe; and this is long before we are confronted by the events of whatever adulthood might bring. Psychotherapists have an understanding that we are all vulnerable beings and we have all been shaped by our vulnerability and our relationships. This perspective allows us to experience a sense of being understood that is rooted in genuine curiosity and kindness. What happened to you? And what was it like?

Kindness

Therapists aim to enter into our experience of the world and understand it with us. This ‘kindness’ should not be confused with ‘being told what we want to hear’ or being placated in a rote way, rather, psychotherapy takes the view that the reactions we have to our experiences are largely understandable, and the things we do to help us cope are usually adaptive in some way, even if they sometimes get us into trouble or cause us other problems.

Psychotherapy involves a certain type of kindness that helps us strike a balance between a shaming blame for our thoughts and actions and a healthy responsibility. It aims to be honest and fair. Feeling we have someone who is genuinely supporting us without judging us, and who cares for our welfare can give us the security to face the complicated areas of our lives and the places where we feel frightened or stuck, with more courage and belief.

Knowing ourselves

Clients often come to therapy with questions – what is happening to me? Why am I feeling like this? Why does X keep happening to me? Why do I act in certain ways? It is frequently the task of therapy to attempt to understand and answer these questions.

Of course, different therapies and therapists will take different approaches to this task, but good-enough therapists try to help their clients explore these areas from a position of curiosity or ‘not knowing’. It is the client’s knowledge of themselves and their questions that must change in therapy, not the expertise of the therapist. We need to know ourselves in a different way from before, and the testimony from clients and the findings of psychotherapy research suggest that we need to discover this knowledge for ourselves, rather than it be ‘told’ to us in a way that might not be real, meaningful or accurate. It our journey and the therapist is simply alongside us.

A relationship

The professional relationship we have with our therapists may on the surface seem to have little in common with the rest of our lives – we don’t do the weekly food shop together; watch TV; or negotiate the various social pleasantries we fall into with other people outside of the usual greetings.

Yet unavoidably we bring the same patterns and tendencies that emerge with other people in our lives. The difference is that now these tendencies have an opportunity to be witnessed, slowed down, discussed and explored without judgement.

The relationship with our therapist becomes a type of microcosm we can use to learn about ourselves. By falling into the same patterns with someone who will not respond like other people would, we are presented with an opportunity to understand who we are and where we are up to, and to experiment with change.

Relating to ourselves

We all have an inner language or ‘voice’ through which we relate to ourselves and the world around us. The origin of this language and how it has been shaped is relatively straightforward to trace – as we usually take in the voices of the people and objects who were once outside us.

Therapy offers us a chance to develop our inner voices for the better through understanding where they come from, how helpful or unhelpful certain voices can be, and whether we would like to develop a new relationship with them.

Sometimes learning new voices is conscious and deliberate, like learning a skill. Sometimes it just starts to happen. Either way we start to move from “what would we say about this in therapy?” to having a new part of us that feels automatic and intuitive.

These categories are of course not exhaustive, nor are they representative of every client, therapist or therapy. However, they hopefully give something of a sense of the experience of psychotherapy and how we try to work at the practice.

We hope to continue exploring some of the most fundamental questions associated with psychotherapy in the coming months, including how to pick a psychotherapist; is psychotherapy effective; and how many sessions will I need.

Until then take care,