Making sense of psychotherapy and psychoanalysis

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What is psychotherapy?
How did psychoanalysis originate?
What is Jungian therapy?
How does psychotherapy relate to psychiatry and psychology?
What's the difference between psychotherapy and counselling?
Why would I need full psychoanalysis?
Is therapy about exploring your childhood?
Isn't psychotherapy self-indulgent?
Will I get very dependent, and not be able to stop?
How do people get psychotherapy?
How much does private psychotherapy cost?
Psychotherapy doesn't have to be one-to-one, does it?
Can psychotherapy help me if I'm a mental health service user?
What if I'm from a minority group?
How do I know which sort is right for me?
What if I think something's wrong with my psychotherapy?
Is there evidence that psychotherapy really works?
References
Useful organisations
Further reading

"My partner said the last thing I should do was go and talk about myself every week; I was self-centred enough already. But it's funny, the opposite's happened.
I sort of feel more in my life, more real. I just get on with things, and I don't get hopeless and desperate like I used to."

This booklet is an introduction to psychotherapy and psychoanalysis. It does not attempt to describe the numerous individual brands of psychotherapy, but looks at the main approaches and explains what the differences are, what you can expect from psychotherapy, and how to find a good therapist.

What is psychotherapy?

Psychotherapy involves conversations with a listener who is trained to help you make sense of, and try to change, things that are troubling you. It is something you take an active working part in, rather than something you are just prescribed or given, such as medication.

Some people are able to get treatment under the NHS from a mental health professional, or through a local voluntary organisation. Others find a private psychotherapist or psychoanalyst. (Information about finding a therapist appears below.) It's possible to work individually, to have couples therapy, or to take part in group therapy or analysis. For anybody trying to find their way round it, psychotherapy is a confusing field. At first glance, there seem to be dozens of different varieties. What has happened is that, over the years, different brand names have arisen for methods that are often variations on a few basic types: behavioural and cognitive therapies; person-centred or other humanistic therapies; psychoanalytic therapies and systems therapy.

Cognitive behaviour therapy
In behaviour therapy, the therapist is a sort of personal trainer, who will show you how to practice facing your fears (for example, of open spaces, social situations or insects) bit by bit. He or she may also be the one to help you if you have problems like an irrational compulsion to wash your hands, or to check things over and over again. In such cases, the therapist will help you gradually to stop these activities, and will support and reassure you while you face the anxiety this change will stir up.

Cognitive behaviour therapy (CBT) also takes a training approach, but this time it trains you to question and control troubling and repetitive thoughts. These can be, for example, miserable, self-hating thoughts, or irrational fears.

Mary has always been an anxious person, but started to have panic attacks after recovering from a road accident. Her heart would race, and she would find herself panting and feeling faint, with tingling and cramps in her fingers. She was terrified that these were warning signs of a heart attack. She went off sick from work and was afraid to go out.

Mary's cognitive therapist listened very carefully to her story, and explained that panic attacks were alarming, but harmless. She gave Mary an information sheet, and asked her to keep a diary of her symptoms. Mary realised that the worst thing had been the fear of the attacks themselves, with a dread of sudden death redoubling the panic. She managed, through the therapy, to regain control of this vicious circle of panic-generating thoughts, and to talk herself down in the way the therapist had trained her to do, when she felt the anxiety coming on. Her attacks ceased and she went back to her ordinary activities.

Behaviour therapy and CBT don't look primarily at what caused the troubling behaviours and thoughts, or at deeper layers of the mind. They work with the immediate, conscious problem, in a commonsense and supportive way. They aim to train you to think and feel differently. Sessions have a clear plan and structure, and you are usually given homework to do in between. Typically, the treatment doesn't last more than a few months, though the therapist will often offer you follow-up sessions. (See Mind's booklet Making sense of cognitive behaviour therapy (CBT).)

Person-centred or client-centred psychotherapy
Unlike a cognitive or behaviour therapist, the person-centred or client-centred therapist won't produce a plan or structure to the sessions, but will encourage you to talk freely about things that are troubling you. He or she will be warm, responsive and non-judgmental, encouraging you to be as open as possible, and to face and come to terms with difficult memories, feelings and fears. He or she is trained to help you to make sense of things in your life and to think about things in new ways, so that you can move on.

Client-centred therapy may be long or short-term, usually on a once-weekly basis. Although the therapist will keep professional boundaries, the role in ordinary life that is nearest is that of a good friend. Your therapist may or may not share some of their own experiences, when they judge that this will be of help to you.

Clive, 21, was confused and ashamed about feeling attracted to other young men at university, especially as his mother kept dropping hints about finding a nice girlfriend. He'd buried himself in study through his teenage years, trying to ignore the growing evidence of his sexual orientation.

Clive got depressed, and saw a male therapist in the student counselling service, who encouraged him to be honest with himself and to explore what his true longings and desires were. When Clive finally came out as gay, the therapist was an enormous support, through being there, reliably, for sessions and relating to Clive in an interested, warm and matter-of-fact way. He was there to listen after the first difficult weekend with Clive's parents, and was a sensible voice and stabilising influence as Clive started to find his way in the complex gay scene of the campus.

Humanistic therapy
There are a number of approaches linked to the client-centred one, which come under the general heading of humanistic approaches. Again, the therapist presents him or herself as an ally, or friendly supporter, and may also have some special technique to offer that aids self-expression.

An example is gestalt therapy, where the client, either individually or in a group, may be encouraged to explore problematic situations not just through talking, but through action. The empty chair technique, for instance, allows you try out a dialogue with an important other, or a part of the self, who is imagined to be sitting opposite you. Other therapies such as art, drama and music therapies also give special ways of expressing yourself besides words.

Psychoanalysis and psychoanalytic psychotherapy
Psychoanalysis and its offshoot, psychoanalytic psychotherapy (also called psychodynamic psychotherapy), is the most ambitious of all therapies in terms of its scope and aims, and approaches from a different angle. It started with the discoveries of Sigmund Freud a century ago, but its methods have changed and developed a great deal since then. It's the most complex of the talking treatments, and has had a significant influence on most others.

The psychoanalytic therapist will seem less socially responsive and immediately reassuring than other therapists, who take more of a trainer or friend role. He or she will ask you to try to say whatever is going through your mind. The analytical therapist will be closely tuned in and empathic, but will also be more neutral, keeping personal feelings and reactions private. As well as giving you a chance to unburden yourself, he or she will also be trying to pick up hidden patterns and meanings in what you are saying. The analytical therapist will also be interested in the way you are relating to him or her, and how this links with other, perhaps problematic relationships in your life.

Psychoanalytic psychotherapy typically lasts much longer than cognitive-behaviour therapy, and you may well need more than one session per week, because it aims to influence deeper layers of the personality, at the sources of the troubling thoughts and behaviour. The most thoroughgoing form of it is full psychoanalysis, where the patient sees a psychoanalyst, four or five times a week, for a number of years. Such intensive psychotherapy is a huge investment, not just of money, but also of time and emotional energy. However, this big investment in one's life can produce significant rewards in terms of the ability (as Freud put it) to love and to work. People find themselves freed to live life more to the full, to be more creative in all sorts of ways, and to relate to and care for others better.

Integrated therapies
Sometimes therapists will also use combinations of different therapies, so-called integrated approaches. One example of this is cognitive analytic psychotherapy (CAT), where the therapist works partly in a cognitive way but also sometimes interprets on the basis of what is happening in the therapy relationship, as a psychoanalytic therapist would do.

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How did psychoanalysis originate?

More than a hundred years ago, the medical founder of psychoanalysis, Sigmund Freud, abandoned a traditional psychiatric approach. Instead he encouraged his patients to lie down in a relaxed position, on a couch, and to try to say exactly what was passing through their minds from moment to moment. He sat out of sight behind them, so as not to distract them. He kept to a strictly professional setting that was confidential and avoided judgement or blame, with sessions at regular times. What he found was that there were all sorts of unconscious and half-conscious fears and preoccupations behind his patients psychological symptoms. These (especially in the repressive late 19th and early 20th centuries) could be worries and traumas of a sexual nature, which they found shaming and disgusting. Often, anxieties were also to do with hatred and aggression; things that conflicted with the way people wanted to see themselves. This is still very true today.

One of Freuds early cases involved the dutiful youngest daughter of a well-to-do Viennese family. Elisabeth stayed at home to look after her parents while her older sister, who she consciously loved, married a handsome suitor. A year later, Elisabeth's sister died soon after giving birth to her first child. Alongside her grief the thought flashed through Elisabeth's mind: Good, now she's dead he might marry me. So horrified was she at having thought this, she immediately pushed the thought out of her conscious mind (repressed it) and became ill, with pains in her legs that limited her social life even more, making her an invalid. The symptom punished her by restricting her life further, but it was also an unconscious compromise. Care and attention was lavished on Elisabeth, including that of the young Dr Freud, who spent regular hours listening attentively to her, until her chains of associations revealed this and other hidden memories and thoughts about her sister and brother-in-law.

Horrified and upset as she was at having to admit to herself her ruthless un-sisterly thoughts, Elisabeth was ultimately much liberated by the work, and could move on in her life. Her pains diminished, she became less involved with her family and was able to get out more. Finally, she fell in love and got married (not to the widowed brother in law!).

Clearly, Elisabeth was a troubled late adolescent, over-involved with her father. She hadn't managed to separate from her family to become an independent, sexual adult. Without help, she might even have got stuck with a long-term career as the family invalid. The therapy helped her to discover that her sexual and aggressive thoughts were thinkable, and that people, including herself, were more complicated and disappointing than she had hoped. Along with these sad realisations opened up many more life possibilities.

Transference and counter-transference
As time went by, Freud deepened his method. Besides unburdening themselves to a sympathetic listener, and retrieving buried memories and feelings, he noticed people repeated troubled relationship patterns in the room with him. This was the discovery of the transference.

Say a young man has a problem with a domineering father. He might appear pleasant and humble, but show secret rebellion about his father's ambitions for him. In Freud's consulting room, he might begin cooperatively saying what was in his mind, but then fall silent, commenting in a friendly way (that might be rather irritating for the ambitious, enthusiastic Freud!) that, sorry, his mind was wandering; that he just wasn't in the mood.

We now know that the counter-transference gives just as important clues as does the transference. The analyst might feel irritated at the patient's silent resistance. He or she then steps back and becomes interested in his or her own irritation. The analyst starts to get the picture of an important relationship both the relationship with the father, but also, more importantly, the whole way this young man deals with others he feels controlled by. This pattern is going to repeat itself with bosses at work. It may infuriate his partner. Worst of all for the man, it will stop him getting what he really wants and needs in life, as so much energy will be wasted in automatically thwarting other people.

Whatever it is you tend to do, and to be, in close relationships, that is what happens sooner or later with your psychoanalyst. And it is for real, and can feel very unnerving. Uniquely, though, you will have a real chance of understanding and changing these patterns.

Paul, who suffered a deprived and abusive childhood, managed a university degree but then after doing a few casual jobs, broke down in his early 20s. He lived a reclusive life over the next decade, unable to work, and beset with fears and grievances, though he continued to read in libraries, clinging on to some hope that he could find a way back into life. He read about a low-fee psychoanalytic clinic, and found the courage to apply. He was taken on by a trainee under supervision, five times a week. Among other things, Paul's troubled relationships with his parents played themselves out in the analytic relationship. He could be submissive but subtly provoking, as he had been with his violent father, or passive and dependent, as with his mother. His analyst had to monitor, carefully, the ways in which she was being unconsciously set up to repeat the past in all sorts of actual and symbolic ways. Instead of automatically reacting, she worked on trying to make sense of what was happening, and talking to Paul about it.

Change was slow and painful but, in time, the liveliness and curiosity that had been squashed and distorted in Paul could re-emerge. He started to take back responsibility for himself and his life, inside and outside sessions. He began to recover his confidence and his pleasure in living and working, and made new friends. Through evening classes, he got back into work, and eventually managed to train and do very well as a teacher.

Further sources of insight
People reveal hidden things about themselves in all sorts of ways, inside and outside analysis. Examples are slips of the tongue, jokes and dreams. Dreaming is the way we think while we are asleep, and it's much less carefully censored than our waking thoughts. Our imagination has a freer reign during sleep, and dream ideas can be revealing and sometimes creative. Dreams can be straightforward, but they often need decoding to reveal the ideas and feelings being expressed, and they can often be useful in analysis.

Since Freud's pioneering work, there have been scores of creative and innovative psychoanalysts who have gone on developing the discipline, particularly across most of Europe and North and South America. London has always been a small but particularly lively centre for psychoanalytic developments. The practice of full four or five times weekly psychoanalysis constitutes a small proportion of psychoanalytically-oriented treatment, but remains an important research base for the psychotherapy profession.

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What is Jungian therapy?

Carl Jung was an early colleague of Freud, whose ideas came to diverge in certain ways. His theories were less centred on the body, and on sexuality and aggression, but retained a link to religious and mystical experience in a way that Freud's did not. Jung was also more interested in later life than in early development. 

Nowadays, many Freudian and Jungian analysts share common ground. Some Jungian analysts and therapists work in a similar way to Freudian psychoanalysts. Other Jungians have an approach that is more humanistic, or client-centred, as described above.

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How does psychotherapy relate to psychiatry and psychology?

Psychiatrists are doctors who have done the usual medical training and now specialise in illnesses of the mind. They may partly think of mental distress in terms of disordered brain chemistry, and often prescribe medication. Psychologists have a university degree in psychology. A clinical psychologist will have gone on to do further study of the human mind in health and distress. Both psychiatrists and psychologists should have basic listening skills, but some do and many don't have formal training in a particular type of psychotherapy.

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What's the difference between psychotherapy and counselling?

There is not a completely clear line to be drawn between some forms of non-intensive psychotherapy and counselling. Counselling tends to focus more on immediate external difficulties and on helping the client with problem-solving skills. Sessions are once weekly or less, and the work is often short-term. Most counsellors will have had a shorter and less intensive training than most psychotherapists.

Different counsellors are trained in different ways of working. Sometimes they are behavioural or cognitive, and sometimes they have a psychodynamic slant. Commonly, the emphasis is person-centred. (See Mind's booklet, Making sense of counselling.)

Psychotherapists and counsellors may come from all sorts of other professional backgrounds, as well as from psychology or psychiatry. Some come, for example, from another helping profession, such as social work, special needs teaching or nursing. Others come to their psychotherapy training from an arts degree.

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Why would I need full psychoanalysis?

When working to understand and alter the fine grain of the mind, the more of a handle you can get on things the better. A daily session during the week, with a weekend break, has proven to be a very efficient method. The level of intensity and intimacy is similar to that of a close family relationship, although in this unusual and special case it is an uneven relationship rather than a mutually sharing one.

Having said this, it would not be possible or practicable for everyone who wanted psychoanalytic understanding to have full analysis. Nor do many people want something this intensive. Most psychoanalytic psychotherapists work between one and three times a week. They employ the same basic ideas and techniques as full psychoanalysis, using the transference and countertransference to help them understand how they relate to others. Much useful work can be achieved in once a week work over a year, or more, and if it's possible to work twice or even three times a week, this will usually feel substantially different from once a week treatment.

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Is therapy about exploring your childhood?

People often find themselves thinking about their childhood, sooner or later, when they let their thoughts flow freely, as childhood is such a formative time. However, that certainly isn't the essential point of psychotherapy. The most important issues concern what is happening now in your mental life, consciously and unconsciously, and in your relationships. So the present and the future are far more important than the past for the past's sake. However, often, childhood still has such a hold on people that they keep wasting the present.

Mary, a 35-year-old single mother of two young boys, had started twice weekly psychotherapy six months ago for panic and depression. She reported: I realise now my head used to be full of my mother, arguments with her, pleading with her, telling her how unfair she'd always been to me. I seem to go on and on to my therapist about it, and actually I've started to argue with her, as well, quite a lot, recently. But it's brilliant, when I'm not in the sessions, there's this clear feeling in my head, mostly. It's not throbbing and buzzing with it all any more.

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Isn't psychotherapy self-indulgent?

You could equally well say that it's self-indulgent to inflict your emotional problems on yourself, your family and your friends, when there might be a way out of them! There are several ways in which exploratory psychotherapy is the opposite of self-indulgent.

Actually, it's quite a brave thing to do to expose yourself to this sort of process. Though it can be relieving and liberating, it can also feel unnerving and painful. You have to face some difficult things about yourself, and think about a lot of things you might rather bury. People usually find themselves becoming much less self-absorbed through such treatment. The world opens up and they stop being so miserably caught up inside their own head.

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Will I get very dependent, and not be able to stop?

The psychotherapist does become a very significant person for you while you are working with him or her, especially if it's an exploratory sort of treatment, like client-centred or psychoanalytic therapy, rather than a short course of behavioural or cognitive therapy. However, people usually turn to help of this sort when something is going badly wrong in their lives. Their freedom is already limited by the way in which their work, family life and relationships keep going wrong in the same old way.

If you go into psychotherapy, you may be starting a relationship that will become intense and deeply important, perhaps for a number of years. However, this is for the ultimate purpose of becoming more independent that is, freer of your dependence on stuck, unconscious patterns of feeling, thinking and behaving. If your psychotherapy seems to be never-ending, something needs looking at. If you are seeing a therapist in the health service, it will probably be for a pre-arranged, limited time anyway, and you will work towards a planned ending. If you are able to have an open-ended psychotherapy, with no set time limit, you will usually find that it turns out to be a naturally evolving process with a beginning, middle and end. If it is allowed to take its own course, it is likely to last years rather than months.

Both therapist and patient usually sense and agree when it's time to set an ending date and to work towards this. That's not to say that it's easy to stop seeing someone you have worked so closely with and grown attached to. But giving up and mourning the therapy itself is actually an important phase of the work.

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How do people get psychotherapy?

The situation is complicated and it can be difficult to find your way around. People living in a large city, particularly London, have access to the most resources. Psychotherapy can be found free of charge in the health service, for full fees in the private sector, and for low or variable fees in various charitable clinics.

Psychotherapy on the NHS is patchy. There are long waiting lists, and you may only be able to have brief therapy with limited choice about who you see and what type of therapy you have. Your first step could be to consult your GP. You may then be referred to local psychology services. They usually (but not always) tend to offer brief behavioural and cognitive therapy. A few hospital psychiatry departments have a psychoanalytic psychotherapy service, and there are also some specialised psychotherapy centres in the NHS. Child and adolescent psychotherapy is also a recognised specialty in the NHS, again more readily available in the big cities, where the training centres are located. This treatment is most often psychoanalytically oriented. Occasionally, psychotherapy is offered to people who are inpatients in hospital or in a therapeutic community.

A number of charities have set up psychotherapy clinics aimed at specific groups of people, including adolescents, people who belong to ethnic minorities, women or refugees. The organisations that offer training in psychoanalysis and psychotherapy often have charitable status, too, and can provide low-fee, intensive psychotherapy to anyone suitable who is willing to be treated by a trainee, under supervision.

Finally, and again most readily available in the larger cities, you can see a private psychoanalyst or psychotherapist. So far, there are no statutory regulations covering the psychotherapy profession, although hard work is in progress to put this in place. This means that you have to take care to make sure that your therapist has had a thorough training, with a reputable organisation, and follows a proper professional and ethical code. It's very risky indeed to take the name of a psychotherapist from a phone book or a shop window, unless they are under the banner of a recognised professional body or you have other knowledge about the person's skills. Often, it's the least qualified people who advertise in this way, while the more professional practitioners depend on referrals through colleagues in their training organisations, or on their name being found on a professional register.

The United Kingdom Council for Psychotherapy (UKCP) is a large psychotherapy registering body, which covers a broad range of different organisations and categories of psychotherapy, including psychoanalytic psychotherapy, cognitive and behavioural therapies, person-centred and many others. The UKCP has a number of different sections for different approaches to psychotherapy. All members are required to meet the minimum standards of training for their particular section, which may or may not include personal psychotherapy, depending on the approach.

The British Confederation of Psychotherapists (BCP) is a specialist, psychoanalytic offshoot of the UKCP, whose individual members are required to have a longer, more intensive training, including personal psychoanalysis. These two umbrella bodies require their member organisations to have disciplinary procedures, ethical codes of practice and requirements for continuing professional development.

Membership of the BCP or UKCP register is a useful guide when looking for a therapist, but getting an additional personal recommendation to a therapist, from a professional or a friend, is invaluable. Before committing yourself, it's important to meet the therapist to see how sensitively they respond to your worries and questions about treatment. Ideally, you should try to meet more than one potential therapist. If you are paying for your own treatment, you will inevitably have more choice about who you see than if you are referred on the NHS.

Fringe therapies
There are approaches not covered in this booklet that use the term psychotherapy without necessarily having a firm professional basis. Approaches of this kind may be based around special techniques or special belief systems. For example, some therapists offer to regress clients back to childhood feelings and experiences. Some give instructions, via the use of hypnosis. Others might combine talking with various sorts of body massage. Sometimes therapies are based around particular, unusual ideas, such as the idea that you need to go through re-birthing in order to solve your problems. Sometimes they are even combined with fortune telling or astrology.

Around these fringes of the psychotherapy world, it becomes particularly difficult to be sure of the qualifications and expertise of the practitioner. People who are desperate and vulnerable may sometimes be drawn into expensive, useless or even abusive situations by would-be helpers, and caution is advised.

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How much does private psychotherapy cost?

The most intensive form of psychotherapy, full psychoanalysis, involves seeing someone four or five times a week. They will usually charge you between £30 and £50 for each session, and that will be for about forty weeks of the year. So we are talking about roughly £8,000 per year, for a number of years. Some fortunate people think nothing of spending this sort of sum on luxury items, such as holidays, cars, and larger houses. For many others, it will be barely manageable or impossible. However, there are opportunities to get low-fee, intensive treatment by having psychoanalysis (five times a week, as Paul did in the example quoted earlier) or intensive psychotherapy (three times a week) with a trainee, who may be able to charge you as little as £10 a session, or even less. Some private therapists are also able to offer a sliding scale of fees to people on lower incomes.

If you live in the right place, and are interested in a low-fee scheme via one of the BCP or UKCP organisations, you will need to go through a careful assessment procedure to see if their scheme is right for you. Most of the psychotherapy training organisations also offer consultations outside their training schemes, and will help you to find treatment of whatever intensity you want or need, whether that is once a week or more frequently. If you are seeing a therapist privately, just once a week, they will probably charge you at the top end of the scale above, sometimes considerably more. Unfortunately, the amount charged isn't necessarily a good guide to the experience and skills of the therapist, as psychotherapy is such a diverse and, as yet, poorly regulated profession. It's always wise to ask where and how a therapist has been trained, and how long they have been qualified.

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Psychotherapy doesn't have to be one-to-one, does it?

Various types of psychotherapy can be done with groups, couples and families, as well. (For information about pursuing one of these options, contact the umbrella organisations listed under Useful organisations.)

Group therapy or analysis
Group therapy sometimes focuses around particular issues, such as drug or alcohol abuse, and the group leader will have a formal educational role. In other sorts of groups, the conversation is free-floating, rather than following a particular agenda, and the leader works in a psychoanalytical way, helping members to express themselves, and drawing attention to patterns of relating within the group.

Therapeutic communities
Sometimes, psychotherapy is carried out within a therapeutic community, where people live, work and explore their difficulties and relationships, together with therapists, in a variety of formal and informal group settings.

Systems approaches and family therapy
When whole families are seen together for psychotherapy, a systems approach is common. Here, the therapist or therapists work with the family to examine the different roles family members have taken on within the family system. For example, it's common for one family member to take on the scapegoat role, expressing distress on behalf of others. A badly behaved child, who has led to the family seeking help, may be distracting everyone from a serious problem between the parents, which needs addressing. Family therapy of this sort is commonly used in NHS child and family services.

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Can psychotherapy help me if I'm a mental health service user?

Everyone in distress needs to be listened to carefully and respectfully by their professional helpers, and users frequently complain that they do not have enough access to talking treatments. It's important that the right sort of treatment is provided, at the right moment.
 
At a time when you might be feeling persecuted and terrified, or very suicidal, you will probably need an approach that is less probing and challenging than at another time when you are feeling stronger and more resourceful. So if you suffer from a psychotic illness, such as schizophrenia, severe depression or manic depression (bipolar disorder), the choice and timing of any psychotherapy or counselling has to be thought about and tailored to your needs very carefully.

Exploratory psychotherapies often stir things up in the slow process of healing, and can make you feel very much worse at times; for example during breaks from treatment. If you have a tendency to psychotic experiences, the process of psychotherapy itself may sometimes trigger one off. This is why some psychotherapists are reluctant to work with people with psychotic illness, or may insist that your psychiatrist or GP are also in the picture.

In some cases, it works better to continue taking medication alongside the psychotherapy, but in other cases, not, and the individual needs to seek advice about this. It's also important to think about the best setting for psychotherapy, for example as part of a day patient, inpatient or therapeutic community setting, or as an outpatient. This will depend a lot on how good your support network is.

Substance abuse
If you are a heavy user of drugs or alcohol, you are unlikely to benefit from exploratory psychotherapy until you are completely free of the substance you are dependent on, and physically recovered. Only then will you have a clear enough head, and enough self-control, to be able to work together with the therapist and to hold on to what happens in the sessions. While you are still using the substance, a structured educational approach aiming to help you free yourself of the addiction will probably make most sense, or a self-help approach like Alcoholics Anonymous or Narcotics Anonymous.

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What if I'm from a minority group?

In the past, people who have most easily found their way to psychotherapy have been well-educated white people. It is emphatically not true to say that psychotherapy is most suitable for such people, simply that they may find access to it easier. Some people mistrust and avoid psychotherapy because it feels culturally unfamiliar, and help-seekers may fear prejudice on the grounds of their sexual orientation or ethnicity. Such fears are mostly unfounded, and NHS psychotherapy departments, for example, actively encourage diversity in referrals.

Good psychotherapy is characterised by its thoroughgoing attempt to understand and make sense of the other's experience, and good psychotherapists are people with openness and curiosity to explore the experience of others very different from themselves. It's also vital that psychotherapists should not blame or jump to conclusions, or dictate the way someone should live. Some people feel strongly that only lesbians can really help other lesbians, and only a Black therapist can really understand another Black person's experience, or a woman another woman's.

Others argue that this risks an artificial avoidance of conflict in the therapy, and that it might make more sense for both therapist and patient to struggle with difference within the therapy room. It's important that this debate continues, but good therapists try to treat every new therapeutic encounter as an encounter with a completely unknown other person. Some therapy organisations do exist specifically for certain minority groups. Above all, it's important that any person with worries about being in a minority group has a chance to explore these complex issues with whatever psychotherapist they are seeing.

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How do I know which sort is right for me?

Ideally, you should have a thorough assessment from an experienced psychotherapist who knows about the different approaches and can advise you, or help you to choose. In practice, the way people reach different sorts of therapy is more haphazard than this, depending on whom they first talk to and what is available locally. Also, how much is needed, and at what depth, may only become clear over time.

Brenda's GP sent her to the practice counsellor, for six sessions of bereavement counselling, when she seemed unable to recover from her depression over the death of her mother, four years previously. Once she started talking, Brenda found that she was far angrier with her mother than she had realised, and had never really forgiven her for all the times her mother had left her with relatives as a child, while pursuing her career. It struck her, for the first time, how her long-term grievances with a female manager at work might be linked to this.

Although things made more sense after the six sessions, she still felt stuck. The counsellor referred her on to the local psychoanalytic psychotherapy service. She waited nearly a year for treatment, but then saw a therapist, once weekly, for 18 months, which finally enabled her to let go of some of her grievances, past and present, have some frank and helpful discussion with her boss, and start enjoying her work again.

Where the immediate, surface problem is a disabling behaviour, such as constantly checking things, washing your hands, or making yourself vomit, a behavioural approach, at least to start with, will make most sense, because it deals with the symptoms that are filling your whole life. This might be all that is wanted or needed, or later you might want to work in a more exploratory way, to try to understand the fears that have been generating and driving your symptom.

Sometimes, people very much want to know more about what is underneath. They can bear to find out things they don't like about themselves, and things that worry and upset them to remember about their lives and families. They welcome, or at least don't mind too much, having their private mental space shared by the therapist. Other people much prefer a more practical, limited approach, restricted to working together with the therapist on changing their surface symptoms and behaviour. So the choice of approach depends both on what is wrong and on what the person wants. Sometimes it takes some time to work this out.

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What if I think something's wrong with my psychotherapy?

Your psychotherapist will be an important figure in your life, and you will have strong feelings about him or her, at times positive and at times negative. He or she will grow to know a lot about you, while you come to know little or nothing about them. This one-sidedness is part of the ordinary course of psychotherapy, but it does require the therapist to have skill and integrity, so that they do not abuse their powerful and responsible position in any way.

The uneven power relationship makes it very important that therapists have thorough and prolonged training and continuing professional development, especially in the form of opportunities to discuss their cases (in an unidentifiable form) with colleagues. They will, hopefully, also belong to an organisation with strict professional and ethical codes and a proper complaints procedure. However, because they aren't, as yet, required to do so by law, you should take great care when choosing a psychotherapist. Even if the therapist does belong to a reputable organisation listed on the BCP or UKCP registers, misconduct will, sadly, occur from time to time, as it does in any profession. Some psychotherapists are simply not very good. A small minority will behave unethically, and may take advantage of patients, sexually or in other ways. The first person to talk to about any complaint is the therapist him or herself. This may prompt a useful piece of work together, leading to a resolution. But, if you are not satisfied with the way your therapist is handling your worries, you should talk to someone else, for instance a friend.

You can also consider approaching the therapist's professional organisation, who will explain to you how their complaints procedure works. If you are still not happy, you might next approach the organisation's registering body, the BCP or the UKCP. There is also a body called the Prevention of Professional Abuse Network (POPAN), which was set up to help in situations like this.

PALS (Patient Advice and Liaison Services) provide confidential assistance in resolving problems and concerns involving NHS professionals. Phone your local clinic, GP surgery, health centre or hospital and ask for details of the PALS. ICAS (The Independent Complaints Advocacy Service) can support you if you are making a complaint about the NHS. To get in touch, contact your local PALS or phone NHS Direct. (See Useful organisations.)

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Is there evidence that psychotherapy really works?

Lots of research has now been done, which shows that, generally speaking, psychotherapy carried out by skilled therapists is effective for many people with many sorts of problems. Longer-term treatment has been shown to have an advantage over brief treatment. Research projects based on large surveys of consumers have come out with very positive results in favour of psychotherapy, and the demand for it often outstrips the supply. The reference list gives a source of further reading about this.

References

Introduction to psychotherapy A. Bateman, D. Brown, J. Pedder (Routledge. 2000)
Handbook of individual therapy (4th ed) ed. W. Dryden (Sage 2002)
A short introduction to psychoanalysis J. Milton, C. Polmear, J. Fabricius (Sage 2004)

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Useful organisations

Alcoholics Anonymous
PO Box 1, Stonebow House, Stonebow, York YO1 7NJ
tel. 01904 644 026, helpline: 0845 769 7555
web: www.alcoholics-anonymous.org.uk
National network for anyone who thinks they may have a drinking problem. Look for Alcoholics Anonymous in any telephone directory

British Confederation of Psychotherapists
West Hill House, 6 Swains Lane, London N6 6QS
tel. 020 7267 3626, fax: 020 7267 4772
web: www.bcp.org.uk
The BCP is the UK umbrella organisation for psychoanalysts, analytical psychologists, psychoanalytic psychotherapists and child psychotherapists. It maintains a register of qualified members

Narcotics Anonymous
202 City Road, London EC1V 2PH
helpline: 020 7730, tel. 020 7251 4007, fax: 020 7251 4006
email: ukso@ukna.org or helpline@ukna.org web: www.ukna.org
For those who think they may have a drug problem

NHS Direct
tel. 0845 4647, web: www.nhsdirect.nhs.uk

Prevention of Professional Abuse Network (POPAN)
52 53 Russell Square, London WC1B 4HP
helpline: 0845 450 0300, tel. 020 7631 5251, fax: 020 7631 1122
email: info@POPAN.org.uk, web: www.popan.org.uk
Helps people who have been abused by health or social care professionals and works towards preventing future abuse

Tavistock Centre
120 Belsize Lane, London NW3 5BA
tel. 020 7435 7111
An NHS centre providing assessment and psychotherapy to adults, children and families. Also runs courses and trainings for professionals

United Kingdom Council for Psychotherapy (UKCP)
167 169 Great Portland Street, London W1W 5PF
tel. 020 7436 3002, fax: 020 7436 3013
email: ukcp@psychotherapy.org.uk web: www.psychotherapy.org.uk
Umbrella organisation for psychotherapy in UK. Regional lists of psychotherapists are available free

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Further reading

The complete guide to mental health E. Farrell (Mind/Vermilion 1997)
A head full of blue: a memoir N. Johnstone (Bloomsbury 2003)
Making sense of antidepressants (Mind 2004)
Making sense of antipsychotics (major tranquillisers) (Mind 2003)
Making sense of cognitive behaviour therapy (Mind 2004)
Making sense of counselling (Mind 2004) 
Making sense of electroconvulsive therapy (ECT) (Mind 2003)
Making sense of herbal remedies (Mind 2004)
Making sense of homeopathy (Mind 2004)
Making sense of lithium (Mind 2004)
Making sense of minor tranquillisers (Mind 2003)
The Mind guide to massage (Mind 2004)
The Mind guide to physical activity (Mind 2004)
The Mind guide to relaxation (Mind 2004)
The noonday demon: an anatomy of depression A. Solomon (Random House 2001)
Understanding anxiety (Mind 2003)
Understanding bereavement (Mind 2003)
Understanding childhood distress (Mind 2004)
Understanding depression (Mind 2004)
Understanding eating distress (Mind 2004)
Understanding manic depression (Mind 2003)
Understanding mental illness (Mind 2004)
Understanding obsessive-compulsive disorder (Mind 2004)
Understanding phobias (Mind 2004)
Understanding schizophrenia (Mind 2003)
Understanding seasonal affective disorder (Mind 2004)
Understanding self-harm (Mind 2003)
The Which? guide to counselling and therapy M. Brookes, S. Wanigaratne (Which? Books 2003)

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This booklet was written by Jane Milton © Mind 2004
ISBN 1-903567-55-6
No reproduction without permission