A beginner's guide to choosing a counsellor or psychotherapist 

An assessment with a experienced psychotherapist is the ideal starting point, but if you are going it alone, in this guide we take you through 3 key steps to choosing a therapist.

 

Step 1: Identifying the problems

DEVELOPING A PERSONALISED DESCRIPTION OF THE PROBLEM OR 'FORMULATION'

Ideally an individualised description or map of the problem(s) should come before making a decision about the type of therapy to go for. In the world of counselling and psychotherapy this is called a 'formulation' and being able to 'formulate' or construct a useful map of the problems is a key skill for therapists. Normally when meeting a client for the first time, a therapist will be looking to gather information so that they can start to construct a working formulation which will serve as a guide when it comes to working out the best way to address the problems. Formulations can be take many different forms but tend to be pull together information about:

  • What the problem is for the person 
  • Historical factors that make someone predisposed to encounter certain problems
  • The circumstances that immediately preceded or triggered the problem  
  • Factors that might be maintaining a problem or keeping it going 
  • Protective factors or things that are stopping the problem worsening

Here is simple example to illustrate what a formulation is.......

Mark has been struggling with low mood and persistent self-critical thoughts (the problems) for the last six months following the breakdown of his marriage (immediate circumstances or trigger). Mark has never had much confidence (historical/predisposing factor) and has always found it hard to believe that any women would want to be in relationship with him. Since the break-up he has been spending most evenings and weekends alone in his flat (maintaining factor) other than when his friend Paul goes to the gym with him on Tuesday nights (protective factor).

Mark's formulation is very basic and often problems are more nuanced and complicated than this but hopefully you get the general idea. If you have pulled together a story of the problems that makes sense to you, you are doing pretty well (you might want to consider becoming a therapist yourself!), If not don't worry - it is normal to struggle to confidently do this without professional help. Although you know yourself better than anyone else, it often requires the right questions and a bit of guidance before you can start to connect the dots. Ultimately it is a team effort - the client brings their intimate knowledge of themselves and the therapist brings a framework for helping the client organise their knowledge in a way that makes more sense.

Even if you don't yet have a complete understanding of the main issues  it is still possible to start thinking about how you might want to go about addressing the problems in a general sense. For example, are you more inclined to focus on resolving the problems as quickly as possible? Or do you want to delve a bit deeper and really get to grips with why the problem arose in the first place? Step 2 takes you through this decision making process in a bit more detail but before moving on to that, let's consider how you might use psychiatric diagnosis reference point for developing your understanding of the problems.

 

USING DIAGNOSIS AS A REFERENCE POINT

Particular types of therapy are more or less suitable for particular issues (to give you an idea the table below lists some common problems and corresponding therapies supported by research evidence) so identifying the type of problem is a sensible place to start. There are different ways you can classify mental health difficulties with the most common being psychiatric diagnoses such Depression and Obsessive Compulsive Disorder (OCD) that you have probably heard of. Without going into a lengthy discussion about the usefulness of diagnosis, it is safe to say that this is not a perfect system for many reasons (if you are interested, here is a link to really good article about this). In addition to questions about how scientifically valid many diagnoses are, typically, people don't fall neatly into one category or another and often experience the kinds of symptoms associated with several different diagnoses simultaneously. For example, someone who has trouble getting on with life because they have to repeatedly clean and check things (symptoms associated with a diagnosis of OCD) might also be feeling pretty down and lethargic (symptoms associated with 'Depression'). Another issue is that there are many people who are experiencing mental distress don't meet the threshold for a diagnosis but this does not mean that they do not have a legitimate reason for seeking help. Issues with diagnosis aside, reading about different categories can provide a useful frame of reference when thinking about the issues you are struggling with because each diagnosis provides a description of common symptoms and experiences that you might identify with. You can then start to build up your own description of the main issues and identify the approaches that are recommended for the categories. It might also help you develop your own formulation or problem description.

If you would like to use diagnosis as a starting point for understanding the issues you are experiencing, take a look at these more detailed descriptions of common problems and diagnoses:

  • Depression
  • Stress and Anxiety
  • OCD
  • Bipolar
  • Voice hearing, unusual experiences, psychosis and Schizophrenia
  • Interpersonal difficulties and Personality Disorders
  • Trauma and Post Traumatic Stress Disorder (PTSD)
  • Medically unexplained symptoms and Somatoform Disorders
  • Health-related psychological problems
  • Eating Disorders
  • Addictions
  • Bereavements, separations and losses

Table of diagnoses and corresponding evidence-based therapies taken UK National Institute of Clinical Excellence (below)

Presenting problem

Psychological therapies supported by research evidence

Depression & Anxiety

Cognitive Behaviour Therapy (CBT) or ‘Third Wave’ CBTs e.g. Acceptance and Commitment Therapy (ACT), Mindfulness-based CBT (MCBT)

Interpersonal Therapy (IPT)

Couples therapy

Dynamic Interpersonal Therapy (DIT)

Psychodynamic psychotherapy

Interpersonal difficulties and Personality Disorders

Dialectical Behaviour Therapy (DBT)

Compassion-Focussed Therapy (CFT)

MCBT

Cognitive Analytic Therapy

DIT

Intensive Short Term Dynamic Psychotherapy (ISTDP)

Mentalization-Based Therapy (MBT)

Relational Groups

Arts Therapy

Bipolar

Family interventions

CBT

DBT/CFT

Trauma/Post Traumatic Stress Disorder (PTSD)

Eye Movement Desensitization and Reprocessing (EMDR)

Trauma-focused CBT

Trauma-focused groups e.g. ‘Breaking Free’ (for childhood sexual abuse)

Community psychology

Obsessive Compulsive Disorder (OCD)

CBT

Systemic Family therapy

Arts Therapy

Somatoform Disorders (symptoms that are medically unexplained)

ISTDP

Systemic Family therapy

CBT (Third wave)

CAT

Psychosis

CBT for Psychosis

Art Therapy

Narrative Therapy

Systemic family therapy

Health-related psychological problems (not medically unexplained)

Mindfulness-based interventions

ACT

Bereavements, divorce, losses

Counselling

Narrative Therapy

Eating disorders

CAT

Systemic family therapy

RODBT

CBT

ACT

Addictions (drugs and alcohol)

CBT

MCBT

 

Step 2: Choosing the right approach for you

 

DIFFERENT THERAPIES APPROACH PROBLEMS IN DIFFERENT WAYS

There are potentially many different ways of addressing the same or similar problems. Without wanting to complicate matters too much, when it comes to mental health, how problems are viewed has important implications for how they are addressed. Formulation or descriptions of problems illustrate this nicely. Going with a 'Mark has an illness called Depression' view of the problem might lead us to think that the 'solution' is a medication that lifts the low mood whereas the formulation of the problem provided in the previous section offers some useful clues about alternatives to medication that might help (although someone like Mark might also find medication a helpful starting point for their recovery). The formulation might indicate a connection between  low mood, self-critical thoughts and a lack of activity. It might also indicate that the lack of self-confidence got in the way of Mark being able to feel secure in his relationship.

If Mark decides he wants a therapy that is going focus on immediate issues such as his inactivity and unhelpful patterns of thinking, an approach that focuses on the here and now such as solution-focused therapy or CBT might be a good fit for him (please note CBT does not only focus on the immediate or 'surface level' issues - this is a common misconception stemming from the fact that the 'here and now' tends to be the starting point for CBT).  If Mark believes his lack of self-confidence and a need for constant reassurance in close relationships is a longstanding issue that he wants to address, this might indicate a relationship-focused approach like Dynamic Interpersonal Therapy (DIT) or psychodynamic psychotherapy might be more suitable.

The next section elaborates on these ideas and will hopefully help you decide if you would like therapy to address the immediate problems and/or the underlying issues.

 

SYMPTOMS-FOCUSED, UNDERLYING PROBLEM-FOCUSED AND STRENGTH-FOCUSED THERAPIES

It is important to start by saying that this is (to some extent) a false distinction based on stereotypes about certain types of therapy. For example, there is a commonly held view that CBT focuses on symptoms and is less concerned about getting to the 'root causes' of problems. This is a somewhat misguided view of CBT stemming from the fact that cognitive-behavioural principles can be used be used flexibly to construct simplistic formulations and symptoms-focused interventions. But, and this is a big but, cognitive-behavioural principles can also be used as a part of 'in-depth' therapies that take into account things like childhood experiences and how people develop beliefs about themselves, others and world. It is important to make this point to prevent people from ruling out CBT as an option because they think that they won't have the opportunity to develop a deeper understanding of themselves. Not true! As a practicising Psychologist CBT is not my preferred approach so this defence isn't coming from any personal allegiance!

Conversely, if you do really want the quickest path to a non-medication-based solution to a problem such as a fear of flying or managing driving test anxiety, you might want to steer clear of some of the less structured, more exploratory and relationship-focused approaches. CBT can offer a quicker for direct solution for these sorts of very clearly defined problems.

There are also what are described as 'strengths-based' approaches which offer an alternative to problem-focused therapies. As you might have guessed, these types of therapies seek to enhance existing capabilities and resources, building resilience and self-confidence. These include Positive Psychotherapy, Strengths-based CBT, Narrative Therapy and Solution-focused therapy.

 

COUNSELLING

It is also important to note that the terms 'counselling' and 'psychotherapy' distinguish between therapy that is primarily about creating a space for someone to talk without this being geared towards finding solutions to problems (counselling) and therapy that is an explicit attempt to address problems (psychotherapy). With this in mind, if you are primarily seeking a space to share your difficulties without judgment and without this needing to be about resolving issues, counselling might be a the right option for you. For example, after a bereavement, separation or loss, people sometimes access counselling to give them the chance to process and adjust to these significant life events.

 

STRUCTURED VERSUS UNSTRUCTURED THERAPIES

What do we mean by 'structured' therapy? When talking about structure I am referring to the extent to which what happens in each session is spontaneous or planned. Structure is also used here as a way of describing the extent to which the purpose of the therapy is clearly defined by measurable goals.

Most therapies and counselling should be guided by some goals or objectives, even if these are broad in their scope but the more structured therapies tend to explicitly work towards a set of goals in a systematic and consistent fashion. In the most structured therapies, at the outset clearly defined and measurable goals are established along with an agreement for the number of sessions and the format for each session. The sessions themselves might begin with the client and therapist collaboratively setting an agenda which also consists of regular items such as a.review of the past week, a review of homework tasks and setting homework tasks for next week. Progress towards goals is regularly reviewed, sometimes using measures and questionnaires. This kind of structure can feel more predictable and less anxiety-provoking and your progress in therapy is clearly monitored so you both know if it is working.  Working towards a predefined end point can also provide a helpful frame for the work.

At the other end of the spectrum you have less structured forms of counselling and psychotherapy. Even in therapies where onus is on the client to use the therapeutic space as they see fit, there will still be some overarching goals that are being held in mind by both client and therapist. For example, the purpose of therapy might be 'to gain a better understanding of why I find intimate relationships difficult'. and an agreement about this from the outset provides a frame for the work (although this may evolve as the therapy progresses). In the least structured therapies, the client is free to talk about whatever comes to mind each session while the therapist helps them to make sense of their experiences through summaries and interpretations. It important to say that less structure does not mean a lack of boundaries. Indeed it is often the least structured therapies have the clearest and most robust boundaries in terms of when sessions begin and end and the extent to which the therapist will share information about themselves with their client. These boundaries are intended to create a sense of safety and consistency so that the client is able use the space constructively and without interference.

Less structured therapies can be a bit daunting to begin with and typically throw up questions like 'what am I going to talk about this week?' and 'what is the therapist thinking?'. The connection between the problems you came to therapy to address and the content of the therapy sessions may at times seem only distantly connected, often leading anxieties about whether therapy is working. Although this can take some adjusting to, the openness of the space can provide a unique opportunity to explore issues and develop new understandings.

It probably makes sense to put therapies on a spectrum with most structured and least structured at each end. The diagram below gives an approximation of where some therapies might fit on this spectrum. As a rule of thumb if a more open exploratory therapeutic space sounds compelling to you it might be worth pursuing a less structured option. Conversely if you think you would find a lack of structure too stressful to be useful, this might suggest a more structured approach would be a better fit.

 

MOST STRUCTURED

CBT for depression and anxiety

Dialectical Behaviour Therapy (DBT)

Mentalization-Based Therapy (MBT)

CBT for psychosis

Cognitive Analytic Therapy (CAT)

Systemic Family Therapy

Person-Centred counselling

Psychodynamic Psychotherapy

Psychoanalysis

LEAST STRUCTURED

 

RELATIONSHIP-FOCUSED VS INDIVIDUAL FOCUSED

All therapies incorporate the client's experience of significant relationships to some extent however some will pay particular attention to how a client relates to others. These include Psychodynamic Psychotherapy, Cognitive Analytic Therapy, Dynamic Interpersonal Therapy, and Interpersonal Therapy. All of these approaches are underpinned by the premise that our wellbeing is determined by the extent to which our emotional needs are being met by those around us. Put simply, in order to feel good we need to feel heard, cared for and have our feelings validated by others.  Of course the people we have around have a major part to play but a significant factor determining whether or not we are able to get our needs met is how we approach relationships. For example if I don't feel comfortable expressing angry feelings towards my partner either because I don't feel justified in doing so or perhaps because I too worried about retaliation, I will try and push the anger away or 'suppress' it. If this is an enduring pattern, anger might start to build up manifesting in a range of unhelpful ways such as behaving passive aggressively (e.g. giving my partner the silent treatment) or directing the anger at myself ("why can't I say how I feel, I'm pathetic" or "why am I getting so angry, I'm are not a nice person").

Relationship-focused approaches will normally try and address these kind of difficulties firstly by helping the client understand how unhelpful patterns of relating developed (IPT is an exception as it tends to focus more exclusively on present relationships). Normally this can be traced back to patterns in early relationships, typically with our parents, which may have become templates that we still use (not always consciously) to relate to others. Continuing with the example of unexpressed anger, I might have learnt at a young age that angry feelings were not acceptable or dangerous to the people around me and as a result I have tended to avoid expressing anger at all costs (without really knowing why). Once unhelpful patterns can be identified an understood, it is them possible to start make changes in how we relate to others.

Individual-focused approaches, focus less on what happens in relationships and more on equipping a client with an understanding of themselves along with strategies and skills that will enable them to manage their problems more independently. CBT is the most prominent example of an individual-focused approach which is underpinned by the assumption that our experience is shaped by our fundamental or 'core' beliefs about ourselves, others and the world. In other words our core beliefs are a bit like lenses through which we see the world but don't even realise we are looking through them.  If you are thinking "I don't exist in isolation so my beliefs about myself and others are to some extent beliefs about relationships" then you are making a valid point! CBT does deal with relationships but places them more at the periphery when attempting to understand and address problems.

In working out what what kind of approach would be the best fit for you, take a moment to think about the role of relationships and how you relate to others in your difficulties. If you immediately think 'yes the problems seem to be stemming from this' then this would probably indicate a relationship focused approach. If not, or you think the relationship focused view is missing something important when it comes to your issues, perhaps a individual-focused approach like CBT might be more appropriate.

 

SKILLS-BASED VS EXPLORATORY THERAPIES

Skills-based therapies are those that are primarily intended to equip someone with the knowledge and skills that enable them to manage psychological problems more effectively. Often these therapies include educational components where the client's understanding of some psychological principles is developed so they can start to understand themselves better. For example, Dialectical Behaviour Therapy (DBT) teaches people things like how to label different emotions and how to tolerate emotional distress more effectively, It starts with learning about certain key principles, understanding these principles through our own experience and practising strategies (in and between sessions) that are proven to help.  Skills-based therapies are not primarily concerned with exploring why difficulties have arisen, more helping a client develop their abilities to manage the difficulties by themselves without resorting to unhelpful coping strategies.

Skills-based therapies such as DBT or Mindfulness-based approaches, can be a crucial first step for many people before they can start to engage in more exploratory therapies that include revisiting painful or traumatic memories. Without these skills, exploring highly emotive topics can be overwhelming, unhelpful and potentially increase the risk of a person engaging in self-injurous behaviour. This is why some therapists might suggest that someone might not be ready for an exploratory or trauma-focused therapy. In addition to a person's ability to effectively manage difficult thoughts, feelings and behaviours, there are a number of other factors than can have a significant bearing on whether it is the right time for someone to start a more exploratory type of therapy. The stability of circumstances and extent to which someone is contending with other difficult life events also need to be considered. For example, if someone is in the middle of highly stressful divorce proceedings it might be more suitable for them to access counselling support in the first instance before engaging in a more challenging analysis of their relationship patterns and early experiences.

For these reasons, it is important to stop and ask yourself.,,,,,,,

(a) Do I want/feel robust enough to start a therapy that addresses some longstanding/underlying issues knowing that the process might be emotionally challenging?

(b) Right now is the priority a therapy that enhances my immediate coping skills even if this does not address the underlying issues?

 

CHOOSING A MALE OR FEMALE THERAPIST

In most cases, this is not crucial decision but sometimes there are very good reasons for choosing a therapist of a particular gender. If a key aspect of someone difficulties are issues arising in close relationships with women, therapy with a female therapist may provide useful opportunities to explore issues that are arising elsewhere. Conversely, for some people,sharing personal information with a therapist of a particular gender might feel uncomfortable to the point where they might not go to sessions. Again while this might present some therapeutic opportunities, if the level of discomfort is going to put someone off going to therapy, it makes sense to choose a therapist with whom you will feel more comfortable. This can be one of the advantages of having a assessment before starting therapy so that issues like this can be explored beforehand. 

 

PUTTING TOGETHER A SHORTLIST OF APPROACHES

Congratulations you are nailing it! By now you should have.......

  • Put together a working formulation or description of the problems and how they have come about.
  • Some idea of where the problems fit in relation to common psychiatric diagnoses.
  • Thought about whether you want address the the main symptoms and/or develop a more in depth understanding of the problems.
  • Considered whether a more or less structured therapy would be the right fit for you.
  • Thought about whether a more or less relationship-focussed approach would fit with the issues you want to address.
  • Considered whether or not a skill-based therapy would be a good starting point before potentially moving onto a more exploratory approach.
  • Worked out if you have any preference in terms of the gender of your therapist.

This should be pointing you towards 2 or 3 types of therapy. Let's use Mark as an example. He has decided that his issues sound most like depression so he is focusing on the therapies with strongest research evidence for depression. He has also decided that he would like to develop his understanding of unhelpful patterns that have been repeated in close relationships and would like to try a less structured approach. Following this logic creates a shortlist of 3 approaches - Dynamic Interpersonal Therapy (DIT), Interpersonal Therapy (IPT) and psychodynamic psychotherapy. At this point it makes sense to do a bit reading about these three types of therapy. Steve decides that DIT and psychodynamic psychotherapy are more appealing to him to because they give more attention to past and present relationships as opposed to focusing on current relationships (IPT). 

From this point, you can start the process of finding a therapist that offers the approach you are looking for in you local area/within your budget. If you are still confused, you can of course register with The Headroom and we can assess you needs and help you find someone (it's free).

Step 3: Finding the best therapist in your local area

 

WHAT REPRESENTS GOOD VALUE?

It can be really difficult working out if you are getting a fair price for the standard of training/level of experience of a therapist given the range of qualifications and approaches on offer. To make this simpler The Headroom has put together a guide to what you should expect pay which you can find here. This guide should help you appraise a therapist profiles and give you a sense of what represents good value for a range of budgets.

 

BASIC ACCREDITATIONS/REGISTRATIONS TO LOOK OUT FOR

The private counselling and psychotherapy market is not controlled by a single independent regulator. Instead there are a number of national bodies that accredit training courses for counsellors, psychotherapists and psychologists. Anybody who has undertaken a training that leads to a diploma level qualification that includes a minimum number of supervised training cases will be registered with at least one of the following bodies (these are the accrediting bodies recognised by The Headroom). If a therapist is not registered with or accredited by one of these it is probably wise to avoid them.

Professional accreditation organisation

Minimum Qualification

Minimum Experience

British Association of Counselling and Psychotherapy (BACP)

BACP accredited Diploma in Counselling or Psychotherapy

450 hours counselling during training

British Association of Behavioural and Cognitive Psychotherapists (BABCP)

Approved basic professional qualification in an appropriate profession (e.g. psychology, psychiatry, nursing, counselling, occupational therapy, social work, education).

Accredited BABCP postgraduate qualification

200 hours counselling during training

UK Council for Psychotherapy (UKCP)

UKCP accredited postgraduate qualfication

450 hours counselling during training

National Counselling Society (NCS)

NCS Accredited Course at Ofqual Regulated Qualifications Framework (RQF) Level 4

100/140 hours counselling during training

Health Care Professionals Council (HCPC)

HCPC accredited postgraduate Practitioner Psychologist qualfication

Clinical/Counselling Psychologists

Minimum 6 hours a week for 3 years = approx 800 hours

Counselling & Psychotherapy in Scotland (COSCA)

COSCA accredited Diploma in Counselling or Psychotherapy

300 hours

SEARCHING ONLINE FOR A THERAPIST

With a growing number of places to look online, this guide should help you refine you search strategy.

1. A good place to start is The Counselling Directory as this is probably the largest register of UK counsellors, psychotherapists and psychologists. The therapist profiles tend to be comprehensive and you can normally find a good amount of information about their skills and, experience.

2. Search the BACP’s website -  it is good for place to search for non-CBT specialists (you will find those on the BABCP website). The majority of therapist registered here specialise in person-centred and psychodynamic approaches.

3. The UCKP website also has a large database  of psychotherapists from a range of disciplines.

3. If you are looking for a CBT therapist, always go to the BABCP therapist finding website first. Many therapist will offer CBT but there is substantial difference between a therapist who has some basic CBT training and a BABCP accredited therapist. They do tend to be more expensive though so if you can't afford £50+ per session you may have to settle for non-BABCP therapist with some CBT training. 

4. If you are looking for Clinical Psychologist you can search the British Psychological Society register (although there isn't much information provided - normally just contact details) or Psychfinder.

6. If you are looking for a Dynamic Interpersonal Therapist or a Psychoanalyst a complete list of register practitioners can be found here at the British Psychoanalytic Council Website. 

7. There are various other websites which are also worth a looking through but have smaller numbers of registered therapists on their books.

-          http://welldoing.org/

-          https://www.therapyweb.co.uk/

-          https://www.therapytribe.com/

-          http://www.rscpp.co.uk/

8. You can also google search the type of therapist and location you looking for and flick through the first few pages. Sometimes you will find a few therapist's websites that are not listed in the other directories. 

 

Good luck! Remember, if you would like help finding a therapist The Headroom can offer you a free phone or Skype assessment with one of our Clinical Psychologists. We will also use our expertise to find you a well matched therapist in your local area - all part of our free service. To get started just complete the registration for below.......