First Talk-What is a Good Psychotherapy Session and Why?
Other forms of therapy Psychotherapy (counselling)
What is psychotherapy?
It is ‘talking treatment’ or, more precisely, as Dr Anthony Storr defined, it is ‘the art of alleviating personal difficulties through the agency of words and a personal, professional relationship’. The professional relationship is established with the object of removing, or modifying, existing symptoms, disturbed ways of behaving, and helping to bring about a positive development in your personality and social life. It leads to an understanding and acceptance of us. The treatment takes place in a safe setting at a time and location set aside for it, with an expectation of confidentiality.
What types are there?
The range of psychotherapeutic methods is enormous. The most common form of psychotherapy is informal psychotherapy or counselling. This can be offered by professional people, but is much more commonly encountered in everyday life in our routine contact with people. It is what happens in the course of normal caring social interaction. It is the help that people give each other when they are trying to help a friend or colleague. It involves giving support and listening, but not expecting any kind of change – just being there for someone.
The next division within psychotherapy is formal psychotherapy or counselling. This takes place in a particular setting at a time that is set aside with a person who has a qualification to help. The psychotherapy may be supportive, or it may be dynamic psychotherapy.
In supportive (formal) psychotherapy, the most common type of psychotherapy, the therapist is aiming to restore the person to their previous level of functioning or, sometimes, just maintain the status quo. Great changes are not the goal. The role of the therapist is as a listener, albeit an ‘active listener’. The aim is to try and reduce the problem into a manageable proportion, to reflect back what has been said in order to clarify the situation, and hopefully to make it easier to see a way forward.
Dynamic psychotherapy is perhaps more challenging. During treatment the therapist is aiming to bring about a change – possibly a permanent change – in the way someone is dealing with their difficulties. A very wide range of techniques are used in this form of treatment.
Questions about psychotherapy
What is the difference between counselling and psychotherapy?
The distinction is often very fine. Generally, a psychotherapist would have had longer, and more formal, training than people who work as counsellors.
What should I expect during psychotherapy or counselling?
Expect to work hard. Therapy is not a passive exercise. You are not going to be told what to do – you will not be told to leave your wife, quit your job, sell your house or change your life. Whatyou will be encouraged to do is to think through all the possibilities of solutions and changes that are available to you, and to see what is likely to be best for you. The therapist will act as a sort of catalyst, enabling things to happen a little faster. Good therapists use ‘active listening’ techniques that help you put whatever is going on in your mind into a clearer form. Once you have started defining your feelings – hearing yourself explaining and telling someone else what the problem is – this often in turn ‘explains’ it to you too. If you are told by someone what to do, you will not ‘own’ that solution nor will you feel committed to it. You will not feel energised to make the solution work for you. If the decision is ‘wrong’, it can be dismissed as someone else’s idea rather than potentially a situation that can be turned around and used to good benefit.
Psychotherapy is aimed at enabling someone to make up their own mind about their own lives. We have much more power over our lives than we tend to realise, and there is nobody who knows as much about us as ourselves. You are an expert on you.
Therapy is challenging. You need to feel fairly strong in order to deal with things honestly. You will not be able to cope well with talking therapies if you are clinically depressed. You may well need treatment with medication before embarking on therapy. It is a good rule to see a doctor before starting treatment.
One of the best ways that a doctor can help prepares someone for successful counselling and psychotherapy is by treating clinical depression first. Your doctor is a good source of information on how to get access to counselling.
Is psychotherapy always done on a one-to-one basis?
No. Some very powerful psychotherapy is done with people working as couples, families or in groups – group therapy. There are also some specialised support groups in which help is given, and mutual support gained by people who share the same problem, for example agoraphobia, overeating or diabetes. Group therapy will also include very widespread and successful groups like AA and NA. The setting, the style and format of these support groups will vary widely.
What therapies are available on the NHS or voluntary sector?
What is available in the NHS does vary depending very much on local resources. Within a hospital district, there should be a psychotherapy service led by a consultant psychotherapist, who would have junior doctors and a team of other professionals working alongside. The NHS psychotherapy services have to be highly selective. It is, sadly, a scarce resource, and waiting times can be lengthy.
Outside NHS hospitals, there is a wide range from traditional and well-established psychoanalytical psychotherapy, to counseling sessions that go on in doctors surgeries. There are many private sources of psychotherapy or counselling, and a number of charities also provide a good service. Your doctor will be able to advice on reputable local resources. A considerable number of people receiving psychotherapy have been referred by their GPs, although many will refer themselves directly to a psychotherapist or counsellor.
How can I choose a good private psychotherapist?
There are some very good psychotherapists available, but there are also, of course, some quacks. One of the safest ways of ensuring that you are having treatment with a properly trained therapist is to check that they are on the United Kingdom Counsel for Psychotherapy (UKCP) Register. Before approaching a private psychotherapist, do make enquiries. A good therapist will not mind this at all. Ask what kind of treatment you are going to be offered and try to arrange to have a preliminary meeting to discuss what the therapist has on offer and what you feel you could get out of therapy. It will also be important to discuss the time that may be involved in treatment. Some therapists are very skilled at brief intervention; other therapists will want to spend many more sessions with their patients. Short therapy is not necessarily bad therapy, and long therapy is not necessarily good therapy.
What might private psychotherapy cost?
Costs will be higher in London. An experienced well-qualified psychotherapist would charge anything from about £35 to £80, or perhaps even £100, an hour. Paying more does not necessarily mean that you are getting better therapy. Therapists in training, who are being supervised, charge less than a therapist who is fully trained. Remember that, if someone is charging a very low fee over a long course of time, you may in fact spend more money than if you were having a shorter course of therapy being charged at average rates.
I have been attending counselling and after the third session I was very upset. The counsellor seemed to be tough with me when I was already feeling bad. Is this fair?
If you are dealing with a difficult problem, it is likely that you are going to have to examine feelings and behaviour honestly. Sometimes reality is harsh, and you will not be helped by somebody avoiding difficult and painful topics. Almost always, if there is going to be a major change, a great deal of effort has to be spent – ‘no gain without pain’. Confrontation may well be necessary during this process. A good counsellor will know how to achieve this in a controlled, respectful and safe way. If you do find anything within a therapy session difficult, this needs to be discussed. Looking at the reason why something is difficult and finding a new way of handling it could be very fruitful.
My family wants me to see a counsellor, but I am not sure that I am strong enough at present to start talking about difficult things.
This is a very important point. Dynamic psychotherapy with somebody who is clinically depressed is very likely to be totally unproductive. If you are experiencing very low mood, supportive talking or therapy will be helpful and sustaining. Some people will need medication initially and then, when they are less depressed, they can make good use of talking treatments. The opposite is sometimes true – some people need to talk things through extensively before they realise that they are actually ill. The process by which they have become ill with depression could have been slow and insidious. There may be a resistance to accepting that illness is present. It may not be apparent until the person has had an opportunity to reflect on the fact that their decision-making, their prevailing mood, their sleep, appetite and libido may all have changed and could be linked to illness that medication could help.
What sort of things will a therapist do with me?
A good therapist will enable you to feel settled and safe enough to talk openly about how you are feeling. An early part of that process, during which trust is developed, is that a therapist will listen in an empathising and understanding way. Therapists need to be totally non-condemnatory, accepting what they hear. They, through the act of their listening, will give the message that what they are hearing is neither shocking, anger making nor shaming. Unconditional acceptance of what is being said, without judgement, is very necessary.
The relationship that develops between a psychotherapist and the patient is very special and safe. Dependence on the therapist can become a problem. It is important that both patient and therapist are aware of this. A good therapist will not be frightened by somebody being very moody at times during their treatment, if they feel that they are leading the patient to a point where they will be stronger and more independent. Good therapy has a clear beginning, middle, and a well-timed and well-planned ending.
My daughter has been going to a counsellor for 2 years and doesn’t seem able to make up her mind about anything without first asking her counsellor. There are undoubtedly some counsellors and therapists who are not aware enough of the risk of dependence – and perhaps even sometimes foster dependence. Good psychotherapy or counseling will enable someone to make decisions. A counseling session can be very usefully used to weigh up the pros and cons of a situation. Using the time to discuss a difficulty is very different from expecting to be told what to do.
Does counselling help prevent post-traumatic stress disorder (PTSD)? We deal with the public in a difficult part of town. Staff does get verbally abused at our front desk sometimes, and this can be quite shocking. Some staff have gone off sick after incidents. Shouldn’t our employer be obliged to provide counselling?
You would imagine the answer would be a resounding yes. Whenever there’s a major disaster we hear of ‘teams of counsellors’ are brought in. However, there is no real evidence from a number of trials that have been done on this question showing that a one-off debriefing session reduces psychological distress, anxiety, depression, or other psychological symptoms, or prevents PTSD occurring. The conclusion from the trials was that compulsory debriefing of victims of trauma should cease.
On reflection, perhaps, this is not surprising. We all deal with shocks and upsets in our own ways. Verbal or physical violence does invade the very core of our own privacy, and trying to intervene in someone’s private feelings at a time of upset might add to the unwelcome invasion of the ‘self’, however well meant it is. Maybe it’s not helpful to review at length and rehearse what happened to you; might this fix it in your mind rather than help you get through it?
Friendly support and sympathy and the offer of time out – if wanted – to get over the upset may be the best approach, rather than a more official exploration of someone’s wounded feelings, which may be intrusive, even disruptive. Some staff may want to carry on as normal after a shock; others will need to let off steam, then or later. It is so important to support colleagues who have had an unpleasant experience. Tea and sympathy always help, but the evidence is clear that obligatory counselling (which may be a contradictory term anyway – you can’t compel someone to confide in you) doesn’t help, and could in fact make the situation worse.
