Can You Think Yourself Well? Part III – Does therapy work?

Let’s talk about it – do talking therapies really work?

The aim of this article is to look at to what extent ‘talking cures’ enable us to deal with unhelpful emotional reactivity, to think and learn our way out of anxiety and depression. We’ll ask: are some types of talking therapy better than others? And, if so, how do we make informed choices?

Identifying the problem

Imagine that you’re lying awake in the middle of the night, mulling over your problems: your parents are getting progressively more frail (your mother recently fell and fractured her hip and your father is not coping well but will not accept any help); one of your children is losing weight and you’re worried that she may be on the verge of anorexia (and you don’t know where to turn to for help); and you feel stalled in your career – you have recently been applying for new jobs but with no success and you wonder whether this means the end of your career progression.

On top of that, three weeks ago you received a letter from the hospital with an appointment for the Breast Unit as a result of a recent mammogram. That is a big deal – an event that caused a big adrenalin rush. Your mouth went dry, your breathing rate increased, and your stomach started to feel strange. It’s still on your mind, added to your other worries, and in the time you’ve been waiting for the appointment you’ve developed eczema on your hands.

During the daytime, you feel generally physically unwell. You have a feeling of dread and you are preoccupied by your worries in an unproductive way. You often feel a little nauseous or slightly overcome by dizziness and you have a persistently low mood. Now imagine that this feeling has become pervasive and persistent and begun to manifest in more frequent panic attacks.

The first scenario is about worrying, and this happens in our mind. The second is a stress reaction and it happens physiologically, in our body. The third is anxiety, and this happens in both our mind and our body. Anxiety is more threatening because it involves both a mental and a physiological response, and it exists on a spectrum from very mild and manageable to more serious and debilitating.

Worry and anxiety in their milder forms can be helpful – they may provoke problem-solving and action, and so result in lower levels of worry, stress reaction and anxiety. However, if anxiety becomes pervasive and persistent and begins to manifest in panic attacks, then we are probably into the realm of a clinically diagnosable anxiety disorder. The line between ‘normal’ anxiety and ‘abnormal’ or clinically diagnosable anxiety is not a clear one. Diagnosis is not a black and white, a ‘got-it’ vs a ‘not-got-it’ issue, but as a rule of thumb, when anxiety is severe enough to adversely affect our everyday experience and performance, we are at the point at which it becomes a clinical issue.

Clinical anxiety often co-exists with depression – broadly, a pervasively low or sad mood that we find a challenge. Or, we may experience a depressive episode in relation to a traumatic event, such as a bereavement; or an extreme depressive episode in relation to a persistent trauma. These kinds of depression may begin to affect our sleep and our eating habits, and our ability to function effectively both cognitively and socially. At this end of the spectrum, like anxiety, depression is clinical. (There are other forms of depression, such as bi-polar disorder or seasonal affective disorder, which have specific physiological causes and need to be treated with specific medications.) Most of the common forms of depression are categorised for diagnostic purposes as Mood Disorders. Again, these exist on a continuum of severity from mild or moderate to major or persistent. For some people, periods of depression are almost integral to their lives – depression is a condition to which they are prone, and that recurs.

Finding help

Thankfully, when symptoms show themselves, many of us will cast around for some help. The GP will probably offer some sort of pharmacotherapy – perhaps anti-depressants and/or possibly some form of talking therapy via the NHS. It’s not uncommon for people to resist the idea of medication, independently searching for a therapist in the belief that talking therapies enable us to ‘think ourselves well’. Therapists in private practice charge anything from £40 to £200 for 50-minute sessions.

When many of us think about talking therapies, we picture ourselves on a couch, with a therapist seated behind us to occasionally challenge us with a question or observation based on something we have said. This image is taken from our understanding of what psychoanalysis entails – starting with what we know of Sigmund Freud from more than a century ago. Psychoanalytically based psychotherapeutic psychotherapies have been defined as treatments that operate on an interpretive–supportive continuum. Interpretive interventions – such as confronting, challenging, asking for elaboration – enhance a patient’s insight into the repetitive conflicts that sustain his or her problem. Supportive interventions – such as strengthening impulse control, setting goals, reality testing and so on – aim to strengthen coping strategies that are temporarily inaccessible because of acute stress. Psychoanalytical approaches are, however, only a subset of the huge variety of ‘talking therapies’ commonly referred to as counselling or psychotherapy.

The following box identifies a reasonably exhaustive list of talking therapies gleaned from the professional body’s websites.

The rather brief and uninformative definitions of these therapies suggest that they are, in fact, slight variations on a particular theme. For example, a cursory glance tells you that the following are all ‘mindfulness’: mindfulness- and acceptance-based therapy, mindfulness-based stress reduction, mindfulness-based cognitive therapy, and person-based cognitive therapy with mindfulness elements… you get the picture. To try to define precisely and/or identify the differentiating characteristics of many of these approaches is like Alice diving into Wonderland. Definitive answers simply don’t exist – and that tends to be true whether you’re trying to define a therapy or understand some other aspect of mental wellbeing.

Who’s who in therapy?

The problems associated with definitions isn’t helped by the fact that there seems to be myriad names for the people we turn to for help: counsellors, psychotherapists, psychologists… What’s the difference between a clinical psychologist and a counselling psychologist; a counsellor and a psychotherapist? A survey of three of the most relevant professional bodies in the area of ‘talking therapies’ (the British Association for Counselling & Psychotherapy, the United Kingdom Council for Psychotherapy, and the British Psychological Society and Tavistock Relationships) offers up the following definitions:

Psychologist – Trained to post-graduate level and achieving chartered status in human psychology and behaviour, clinical or counselling psychologists specialise in treating diagnosed conditions with a variety of therapies, but most often CBT. They tend to work within the NHS and specialise in particular areas such as adult or child mental health, neuropsychology, or older adults. The ‘clinical’ or ‘counselling psychologist’ title is professionally restricted, which means it’s illegal for anyone not properly qualified to go by this job title.

Psychotherapist – A blanket term given to anyone who treats psychological distress through some kind of non-medicine-based intervention or therapy. The job title often implies that the individual has undergone training based on psycho-dynamic or psychoanalytical theory and techniques. However, anyone can call themselves a ‘psychotherapist’ – they don’t have to be a psychiatrist or psychologist. Psychotherapists may have done long, thorough trainings or short, more cursory ones. Only through accredited training will they be able to register with a professional body. 

Counsellor – A blanket term given to anyone who treats emotional or life distress through some kind of non-medicine-based intervention or therapy. Counsellors tend to use ‘lighter-touch’ treatments than psychotherapists and this generally means that counselling interventions are short-term. Their training tends to be shorter, and may be thorough or cursory. Anyone can call themselves a ‘counsellor’ but, as for psychotherapists, they will need to have undertaken accredited training in order to register with a professional body. 

In short, then, psychologists are trained to a high academic standard with a period of supervised practice to enable them to become chartered; psychotherapists tend to have a longer training than counsellors, but they both ‘treat’ the same kinds of issues; and a course of counselling may be shorter than a course of psychotherapy. Importantly, anyone can call themselves a psychotherapist or a counsellor – you may have encountered a burgeoning group calling themselves ‘life coaches’ – although registration with a professional body acts as a guarantee that the person has completed an accredited training course. Finally, psychotherapists and counsellors may be easier to access than psychologists, as they more often tend to work in private practice. 

Does the type of therapy matter?

It is a commonly held belief that Cognitive Behaviour Therapy (CBT) is the most effective form of ‘talking cure’. CBT is probably the most prevalent, having been identified by NICE (the UK’s National Institute for Health Care and Excellence) as the therapy with the strongest evidence base for its cost effectiveness. It has subsequently been promoted strongly within the NHS through IAPT strategy (Improving Access to Psychological Therapies). IAPT does not draw on CBT exclusively, identifying ‘Evidence-based psychological therapies’ more broadly, but CBT is undoubtedly a key component of the offering. 

CBT is based on a process of understanding the relationship between thoughts, feelings and behaviours and challenging the (often) negative thoughts or beliefs that lead to unhelpful feelings and behaviours. The therapeutic process is usually very structured and involves three main elements: strategies for addressing core beliefs, cognitive restructuring (challenging and reframing unhelpful thoughts or beliefs) and behavioural activation (learning and using skills to address unhelpful thoughts or beliefs). Clients are usually given ‘homework’ so that they can practise the skills they learn during guided treatment. In NHS settings, CBT is usually offered for a fixed number of sessions, and it is often viewed as effective in a short (6–9-month) period of time. 

That’s all well and good – but does it work?

The answer to that is a qualified yes. CBT is reasonably effective in helping with a range of anxiety problems, including generalised anxiety disorder, although it shows the best results when focused on specific anxiety problems (such as Obsessive–Compulsive Disorder). It can sometimes help to reduce some depression symptomatology, but, perhaps unsurprisingly, is generally less effective in this area compared with other evidence-based psychological therapies in the treatment of depression.

Other therapies that have been found to be effective in reducing the severity of symptoms of anxiety and sometimes depression include Mindfulness- and Acceptance-based therapies, Integrative Counselling, Counselling for Depression and Transactional Analysis. Ultimately, a sizeable evidence base now exists that concludes that CBT is not significantly more effective than a number of other talking therapies.

Talking therapies vs antidepressants

One key meta-analytical study comparing psychological interventions with ‘usual GP care’ and/or antidepressants found that psychological interventions were more effective than usual GP care in both the short and the long term, but that the outcomes were not significantly different from those seen with antidepressant use. The evidence as a whole suggests that CBT (and other therapies) is neither more nor less effective than antidepressants alone in the treatment of depression, and the consensus arising from the data is that the most effective way to treat depression, in the short term (although not longer-term), is a combination of anti-depressants and CBT.

Can we really compare therapies?

One of the main problems with research into the effectiveness of talking therapies is the difficulty in identifying and defining them in a way that makes them distinct enough from one another to clearly compare and contrast. A fairly exhaustive examination of the current research evidence fails to identify clear conclusions, in part because there are so few good-quality studies that look at interventions other than CBT-based approaches.

At best, we could probably say that most talking therapies have some beneficial effect, but the extent of the effect is unclear and often not necessarily clinically significant (as assessed by independent evaluators looking at a positive change in symptoms). In other words, taking the plunge and engaging with therapy might make you feel better in some way, but whether or not it has a significant effect in terms of reducing your symptoms is still in question.

Does it matter who your therapist is?

Yes, it does. So-called ‘therapist effects’ (particularly a therapist’s interpersonal functioning and skills) can significantly influence the outcome of your treatment – even more than the type of therapy you have. And, as we might predict, some therapists are a lot more effective than others – in some cases consistently twice as effective regardless of case-mix (such as the clinical diagnosis and symptom severity). Therapist effects explain between 5% and 9% in the variance in outcomes, although this figure ranges widely by setting. Furthermore, therapists are considerably less likely to be effective with more severe patients. 

Differences in the effectiveness of therapists occur across a broad range of settings – that is, whether a patient receives therapy at a university counselling centre, primary care setting, specialistic clinic, or somewhere else. In primary care settings, patients are likely to be offered a shorter course of therapy, with 6 sessions being the average. (NICE advises 6–20 sessions of CBT for depression.) 

What are therapist effects?

Many studies have looked at the various aspects of therapists’ interpersonal functioning and skills. These skills include, for example, an ability to show a nurturing approach, showing warmth, demonstrating protective and helpful behaviours, and also showing verbal fluency, empathy, emotional expression and an ability to convey a non-judgemental attitude. More interpersonally engaged and extraverted therapists achieve faster symptom reduction (unless they are prone to excessive self-disclosure), whereas less intrusive therapists seem to better benefit patients engaged in longer-term therapy. Similarly, a therapist’s own mental health (for example, attachment security and positive self-concept) appears to have a relationship with that therapist’s effectiveness. Nonetheless, the relationship is not a straightforward one – it’s often moderated by interpersonal factors. 

Ultimately then, a number of interpersonal skills contribute to the relationship between therapist and client – the ‘therapeutic alliance’. The strength of the therapeutic alliance seems to be the key factor in determining how successful a course of therapy will be. If a therapist fails to recognise and repair issues with the alliance, the outcome for the client is likely to be less successful than it might otherwise have been. In other words, if a therapist focuses on you, the client, and makes you feel heard, cared for and not judged, then you will probably feel better for having had the therapy. It also seems to be the case that if you find yourself with a below-average therapist, your outcome prognosis will become worse the greater number of sessions you have – simply, having multiple therapy sessions with a poor practitioner could be bad for your mental health. 

Another relevant factor in this equation is the extent to we expect to engage positively with the therapy. In other words, if we expect that the therapy will work, then we are more likely to benefit. 

Of course, even if at the start of a therapy we have really positive expectations, we have no way of knowing whether the therapist is more or less competent. Even diplomas framed proudly on the wall are no real measure of ability – yes, the therapist has passed the courses in order to receive the certificates, but the system provides no process for independent review and appraisal of a therapist’s competence. 

Does delivery matter?

There’s one final aspect of talking therapy to consider: is in-person, individual face-to-face therapy necessarily better than therapy delivered in a group setting or virtually? Possibly not. 

A number of meta-analytic studies have shown that, when it comes to treating anxiety or depression, web-based or computer-delivered CBT interventions (usually support that comes in the form of a reminder) are about as effective as other types of non-computer delivered intervention or an active control group. 

Other meta-analyses have compared computer-delivered CBT (iCBT) with a range of other digitally delivered types of therapy (Attention Bias Modification, Exposure Therapy, Applied Relaxation, Bibliotherapy, Psychodynamic Therapy, Mindfulness, Behavioural Stress Management and Counselling among them) in treating a range of conditions. It found that iCBT was effective in treating Social Anxiety Disorder, and although some of the other interventions were also moderately effective, the evidence was less statistically compelling. In comparing iCBT with face-to-face CBT, the former was found to be an effective treatment, although it is unclear as to whether or not it was as effective as meeting the therapist in person. In addition, the evidence suggests that iCBT interventions need to include some guidance and prompting to ensure that they are as helpful as they can be. Interestingly, though, this need not be human guidance or prompting. 

Finally, a number of studies have shown that iCBT is less effective with children (aged between 5 and 11) than with teenage or adult patients. This is perhaps unsurprising, as engaging effectively with CBT requires a level of linguistic and cognitive competence that younger children may not yet have.

As with so much in this area, there is still a lack of good-quality research to enable us to be definitive about one form of delivery compared with another, but the evidence we do have does suggest that digitally delivered CBT can be effective in treating some forms of anxiety and depression.

Conclusions

So, how can we summarise what the evidence base is telling us overall?

• It is better to engage with some form of therapy than not to have therapy at all – we are likely to feel better, because we have taken steps to take back control. 

• Engaging with therapy and having a good relationship with a therapist has a positive effect on mood – we feel better, even if, considered objectively, our symptoms are not reduced.

• CBT is the most widely researched type of therapy because (a) it has a coherent conceptual/theoretical basis, aspects of which we can clearly define and measure, and (b) because, broadly speaking, the NHS has supported it and made it available, giving us a sizeable database for research. The two things feed off each other, contributing to a self-fulfilling prophecy.

• As a prevalent type of talking therapy, CBT is reasonably effective in treating social and/or general anxiety and some less severe depression, especially when accessing mental-health services through the NHS. 

• If we engage with therapy with a conscientious attitude – ‘I fully intend to apply myself and do the necessary work’ – and complete the programme of sessions, we are more likely to get a positive outcome.

• Research aimed at assessing the effectiveness of forms of therapy other than CBT is of much poorer quality, with conclusions drawn from small sample sizes and unreliable or poor-quality measurements. 

• It is probable that some of the other types of bonafide talking therapy can also be effective in treating anxiety and depression, but evidence available is not of a good enough quality for us to be able to draw reliable conclusions. 

• Evidence suggests that neither talking therapies nor medication alone is better than the other at treating depression, but used in combination they work well. 

• Some therapists are much better than others, a poor therapist can do more harm than good, and the specific therapist that we find ourselves with is much more important than the kind of therapy itself. 

• It’s impossible to know how effective or competent a therapist is as there are no consistent assessment standards by which practitioners are measured.