Choosing a therapist

Start with the fact that most people do not know, because everything else follows from it. In the UK, "counsellor" and "psychotherapist" are not protected titles. Anyone may use them. No qualification is required, no training, no registration, no supervision, no insurance and no complaints procedure. "Psychologist" on its own is not protected either.

That is not a reason for alarm — most practitioners are properly trained and belong to a professional body. It is a reason to check, because the title on the door tells you nothing and the person choosing is usually choosing at the point in life when they have least energy for due diligence.

What is protected, and by whom

Some titles are protected in law, and using one without being registered is a criminal offence.

• Practitioner psychologist, and the specific forms — clinical psychologist, counselling psychologist, educational psychologist, forensic psychologist, health psychologist, occupational psychologist, sport and exercise psychologist — along with "registered psychologist". These are regulated by the Health and Care Professions Council.
• Art therapist and art psychotherapist, drama therapist, music therapist, also regulated by the HCPC.
• Doctor, which is how psychiatrists are regulated: they are medical doctors on the General Medical Council register, with a specialist registration in psychiatry.

Everything else — counsellor, psychotherapist, CBT therapist, psychotherapeutic counsellor — rests on voluntary registration. Which brings us to the registers.

The registers, and how to use them

The Professional Standards Authority accredits voluntary registers. Accreditation does not vouch for an individual, but it does mean the register sets requirements for training, supervision and insurance, holds its members to a code of ethics, and operates a complaints process that can remove them. The main ones in this field are held by the BACP (British Association for Counselling and Psychotherapy), the UKCP (UK Council for Psychotherapy), the NCPS (National Counselling and Psychotherapy Society), the BPS (British Psychological Society), the BPC (British Psychoanalytic Council), and the BABCP, which is the one to look for in cognitive behavioural therapy.

The practical instruction is short: search the register itself rather than reading the claim on the practitioner's own website. Each of these bodies publishes a searchable directory, membership can lapse, and logos on a website are not evidence. For a psychologist, search the HCPC register; for a psychiatrist, the GMC register.

One limitation is worth understanding. Removal from an accredited register ends membership of the others — but it does not stop someone practising under an unregulated title. That is precisely why checking is on the client rather than on the state.

Who does what

More letters after a name does not mean a better fit for a particular problem.

Counsellors typically work with specific difficulties and life events — bereavement, relationships, work, a period of distress — often over a defined number of sessions.

Psychotherapists generally train for longer and work with more entrenched or longer-standing patterns, often over a longer period.

Clinical and counselling psychologists are trained in assessment and formulation as well as treatment, usually across several therapeutic models, and tend to be the people seen for more complex presentations.

CBT therapists are trained in a specific, structured, time-limited approach with a strong evidence base for anxiety disorders, obsessive-compulsive disorder, post-traumatic stress disorder and depression. Cognitive behavioural therapy sets out what that actually involves.

Psychiatrists are doctors. They diagnose, prescribe and manage medication, and are involved where that is part of the picture. Some also do psychotherapy; most do not. A psychologist or counsellor cannot prescribe.

Matching the approach to the problem

For several conditions there is a reasonable answer rather than a matter of taste, and NICE publishes recommendations by condition — which makes "what does the guideline suggest for this?" an entirely fair question to ask a practitioner.

Broadly: cognitive behavioural therapy and its relatives have the strongest evidence for anxiety disorders, panic, OCD, PTSD and depression, with EMDR also well supported for trauma. Interpersonal therapy is well supported for depression. Mindfulness-based cognitive therapy is recommended for preventing relapse in people who have had recurrent depression. Counselling and psychodynamic approaches are appropriate for a broader range of difficulties, including those that are less easily reduced to a diagnosis.

Against all of that sits a finding that is consistent across the research and worth taking seriously: the quality of the relationship between client and therapist is one of the better predictors of whether therapy works — for many problems a better predictor than which brand of therapy is used. So "fit" is not a soft consideration to be weighed against the technical ones. It is one of the technical ones.

What a good practitioner does early

• States their training and registration without being prompted, and does not mind being asked.
• Explains how they work and why that approach suits the problem.
• Sets out fees, session length, frequency and cancellation terms before treatment starts, in writing for private work.
• Explains confidentiality and its limits.
• Says roughly how long the work might take and how progress will be reviewed.
• Is clear about what they do not treat, and refers on where something is outside their competence.
• Has clinical supervision, and insurance.

Warning signs

Any one of these is a reason to stop and think; several together are a reason to leave.

• A practitioner who talks mainly about themselves. A brief, purposeful disclosure is a recognised technique, used sparingly and for the client's benefit. A therapist whose own life, opinions and troubles are a regular feature of the session has a boundary problem. It is sometimes mistaken for closeness, and it is not: the hour belongs to the client.
• Any move towards a relationship outside the professional one — social, financial, business. And unambiguously: sexual or romantic contact between therapist and client is a serious ethical breach, is never acceptable, is not the client's fault, and should be reported to the practitioner's register.
• Pressure to commit to a long or expensive course of treatment up front, or to pay for many sessions in advance.
• Promises of a cure, guarantees of results, or claims to treat conditions far outside any plausible competence.
• Evasiveness about training or registration, or irritation at the question.
• Discouraging contact with a GP, suggesting prescribed medication be stopped, or advising against other treatment. No therapist should be advising on medication unless they are the doctor who prescribed it.
• Telling a client not to discuss the therapy with anyone.
• Promoting a belief system, religious, spiritual or ideological, as part of the treatment without that having been agreed at the outset.
• Repeatedly crossing agreed limits on time, money or physical contact.
• No complaints route, because there is no register behind them.

Feeling uncomfortable in a session is not in itself a warning sign — therapy is frequently uncomfortable, and avoiding discomfort is often the thing being treated. The distinction is between feeling challenged about the problem and feeling uneasy about the practitioner.

If it is not working

Say so, in the session. A competent therapist will treat that as material rather than as an attack, and reviewing it openly sometimes shifts the work substantially. If it does not, it is reasonable to ask for a different approach, to ask to be transferred to a colleague, or to stop. Through an NHS service, ask the service.

Where something has gone wrong rather than simply not worked, the route is the practitioner's register, which can investigate and remove members, and the service's own complaints procedure for NHS treatment.

Cost, and the routes that are not private practice

Private therapy is not the only option, and for many people it is not an affordable one.

• NHS talking therapies in England can be self-referred to, free, with no diagnosis needed.
• Charities — Mind and its local associations, and condition-specific organisations — run free and low-cost counselling in many areas.
• Training institutes offer low-cost sessions with trainees under close supervision, which is often better supervised than ordinary private work.
• Employee assistance programmes, offered by many employers, provide a short course of counselling free and confidentially.
• Universities and colleges have their own counselling services.
• Many private therapists hold a number of lower-fee places and will say so if asked directly.

See also the first therapy session and mental health, which lists the routes to help and the crisis lines.