​In recent years a story appeared in the New York Times about a woman who had spent decades in therapy and didn’t think it had worked. It provoked heated debate. Had she been used badly by an exploitative profession, or was she herself at fault for persevering in a therapy that she could plainly see was ineffective?

Unfortunately, questions like these don't have easy answers. However, they do indicate the need for people to think wisely about their choice and usage of therapy.

The good news about therapy is that mostly it works. Whatever kind of therapy you do, you are likely to find relief from distress and gain psychological benefits.  

On the other hand, things can and do go wrong. A widespread and insidious problem in my experience is the one described above: an ineffective therapy, or one that makes the client feel worse.

How to steer clear of this?

It is all too easy at moments of psychological distress to make hasty and ill-judged choices. Yet it is critical to be a discerning therapy shopper and consumer – after all, this is a purchase that could affect your whole life.

Here are my top tips.

1. Get support while you are looking for therapy

If you’re in distress, ensure you have some form of immediate support to tide you over while you investigate other possibilities. Make regular contact with close friends – the ones you can really talk to; talk to the Samaritans (they don’t just deal with the suicidal); go to a self-help group in your area.   

It is essential to ensure that your life is rich with activities known to enhance wellbeing: exercise, doing things to ‘detach’ from everyday worries (meditation, creative activity, the arts), connecting with other people, doing things that give you a sense of deeper meaning or purpose in life, learning and experimenting, and – surprising as it may seem – helping other people.

Even when you find a therapist, don’t have all your emotional eggs in one basket. If you feel reliant on a therapist to tide you through from week to week, you will find it harder to be objective about therapy’s usefulness to you. Worse, therapy may become a ‘crutch’ supporting a dysfunctional life, rather than a route to change.

2. Get informed and clear about what you want

There are at least 400 different kinds of therapy based on very different ideas.  Many of these are effectively different ‘brand names’ for a broadly similar process.  However, there are some radical differences between therapies in terms of what problems they are known to address; their underlying belief systems; the nature of the process, and the cost and time commitment involved.  

Think carefully about your own personal ‘therapy spec', talk to potential therapists about what you want, and ask them whether their approach fits with your own needs and wishes.   Here are some of the factors to consider.

  • Do you want relief from specific symptoms (which ones?) or to get support through a crisis? Do you want to change a behaviour, or to understand yourself and the meaning of your life better?  Are you looking for support to make a big life-change?  
  • A key difference between therapies is that some focus primarily on symptom-relief (often by changing problematic patterns of thought and behaviour), whilst others focus more on self-insight through an exploration of your life history. The former tend to be more short-term (up to 10 sessions), the latter much longer (often many years).  

Importantly, none of these types of therapy has a monopoly either on effectiveness or on the truth - all of them work. However, what has been shown to be the case is that the therapy should ‘make sense’ to the client if it is to work. So whatever therapy you choose, your therapist’s way of describing it and talking about how you will get better should make intuitive sense to you

In my own personal view, it is important for the therapeutic process to be both insight- and action-oriented – i.e. to help you  on one hand understand and have compassion for why you are the way you are, but also to help you change unsatisfying patterns.

3. Chemistry, chemistry, chemistry

The key thing that makes for success in therapy is your relationship with the person you see.  This has been shown to be more important than factors such as:

  • The type of therapy 
  • Years of training and experience your therapist has 
  • Their qualifications

In therapy research, the positivity of the relationship is described as a ‘good therapeutic alliance’ and is known to be the best predictor of therapy success.  In practical terms, think of this as ‘good chemistry’ – a sense that you ‘click’ with your therapist, and that they understand and feel warmly towards you.

Famous, expert and very senior therapists are not necessarily the best ones. It is a myth that therapist experience, training and seniority correlate with therapy success. 

4. Look for a therapist who pays attention to results

One important characteristic of therapists who perform well is that they are often people who have a particular commitment to improving their outcomes.  This means that they have some means of regularly getting feedback from clients on how they are doing.

This is important as it has been shown that therapists have a tendency to be (to put it kindly) optimistic or (to put it less kindly) deluded about how they and their clients are doing. Rather like driving – where 85% of drivers estimate they are in the top 10% when it comes to driving skills – 90% of therapists believe they are in the top 25% of therapists when it come to getting good outcomes. Moreover, it has been shown experimentally that therapists are poor at spotting the signs of a faltering therapy; in fact, a computer programmed with the right algorithms has been shown to be more accurate.

All this means that you should look for a therapist who takes an active interest in regularly reviewing your progress, even if in an informal way.

5. Don’t take a passive attitude

Don’t regard therapy as a ‘treatment’ in the usual sense - your own effort is the most important thing. In the end, therapists are more analogous to teachers or personal trainers than to doctors. You can’t lie back and expect to be healed; a therapeutic process is about a) learning about yourself, your resources, and how to change problematic patterns and b) applying that learning in your everyday life.  

6. Review your choice and don’t stick with what is not working

With any therapist, I recommend a trial period. Explain that you would like to see how it goes for a few sessions before you commit for any longer.  Research has shown that generally it is apparent after the first three sessions whether or not a therapy is going to ‘work’ for you or not.  

Nobody should buy into the myth that ‘you have to get worse before you get better’. Instead, when researchers have tracked the therapy process, it has been found that the general pattern in good therapies is to get a bit better at first, followed by getting a lot better over the longer term.

This is not to say that you will not cry, feel angry or ‘churned up’  in the first few sessions. But there is a difference – as with exercise - between ‘good pain’ – the kind that leads to emotional relief and personal change – and ‘bad pain’.  Warning signs of the latter are:

  • Feeling that your therapist is cold, aloof or doesn’t care about you
  • Finding your therapist’s comments critical or bruising
  • Feeling uneasy about the appropriateness of your therapist’s behaviour 
  • Your therapist makes no attempt to find out about or meet your therapy goals

It may feel  a wrench to get out of therapy once you have started; when people feel desperate, they are inclined to cling on to the straws of hope they can find.   

However, ask yourself if you would recommend what you are doing to a relative or close friend in distress. If your answer is ‘no’, it’s not good enough for the ones you love, it’s not good enough for you.

I would strongly recommend that if after three sessions the therapy experience is offering you nothing positive you move on and find something else. There will be plenty of other therapists who can help.

Find the right therapist for you