From influencer therapists on social media to psychotherapy platforms advertising on TV and radio, going to see a therapist is increasingly mainstream – yet many people know little about who they are seeing and what they are getting.
Experts said more information and awareness among the public of how therapy works was desperately needed, to minimise the risks of making their mental health worse.
“The public needs more understanding that psychotherapy can do good but it also can do harm, and anything that’s powerful enough to change your life for the better is powerful enough to do some damage if it’s in the wrong hands and done wrongly, or recklessly,” said Glenys Parry, an emeritus professor at the University of Sheffield and an accredited psychotherapist.
Parry said there was very little good research evidence to establish the extent of the harm caused by underqualified therapists. In most cases, the evidence suggested therapy does good, with research suggesting around 5-8% of people feel worse after therapy, she said. However, she added that it was particularly hard to research “the wild west situations like the online areas”.
One red flag, she said, was therapists who say “you have to feel worse before you feel better”, and another was when a therapist did not discuss expectations with the client. “The therapist has to assess risk, and some don’t. They plunge in without understanding anyone’s vulnerabilities or a history of psychotic breaks,” she said.
Part of being able to do this was understanding “the limits of their competence”, and knowing how to signpost specialist services, for example a psychiatrist or a neurodiversity expert, if needed. She said NHS therapists tended to come under more scrutiny and were therefore a safer bet.
“One of the reasons therapy goes wrong is transgressive therapists who are literally abusive or exploitative, and they are in the minority, but they do exist,”’ said Parry. “But much more common are people getting in out of their depth, they don’t understand the limits of their competence – they’re trying their best to be helpful but they’re not able to see they’re making things worse.”
Parry added that there were so many different models of psychotherapy, from cognitive behavioural therapy (CBT) to psychodynamic therapy or counselling, there was now “quite a lot of evidence people don’t really understand what it is they’re getting”.
Regulation would help ensure that all therapists have an agreed minimum level of training and experience, and would be expected to keep up with new research and professional updates. For example, research from the University of Portsmouth suggests that asking a person to talk about their parents in therapy can distort memories of childhood emotions, and that therapists should communicate this to clients.
Dan Poulter, an NHS psychiatrist and former health minister, said: “When you come across some patients who tell you they’ve been seeing a private counsellor or psychotherapist, I often take an inward groan and worry about whether that’s done more harm than good to the patients I see. There can sometimes be professional overreach by some psychologists who are not trained to diagnose mental health conditions in the way a psychiatrist is.”
Part of this is due to the “self-stigma” sometimes attached to the idea of seeing a psychiatrist. “Therefore, sometimes the first thing they may do is talking therapy rather than going to see a GP,” he said. “It’s not always in the interests of the psychotherapist to challenge the person’s self-perceptions or refer them on to somebody else who might be more suited to helping them. The model in place at the moment doesn’t always encourage responsible professional practice in that respect.”
For example, someone who has psychosis because of an illness such as bipolar disorder or schizophrenia will need to be prescribed medication. “If you don’t have the skills to diagnose that, or you have a financial interest in keeping a patient on your books, and there’s no recourse for bad practice … there’s a real patient safety issue. It doesn’t help the cause of mental health more generally … We want patients to receive the right help as quickly as possible.”
Callout
Prof Dame Til Wykes, the head of mental health and psychological sciences at King’s College, London, said many people were turning to the proliferation of online mental health apps, despite the fact “not many have had any randomised controlled trial or even any observational study”. The way such apps were marketed, she said, resembled companies “selling snake oil”.
Without supervision from a trained therapist, she also warned that “some things for some people can make the individual worse”.
Lisa Morrison Coulthard, the director of professional standards at the British Association for Counselling and Psychotherapy, said one concern members had was the rise of influencer therapists, whom they had seen share “unhelpful or damaging support online”.
On platforms that connect therapists and clients, she said, “there’s just no guarantee what you’ll get”, in particular with those that operate out of different countries.
“Given the mental health crisis, which is developing into a mental health emergency in terms of rising rates of young people, as well as adults, seeking that therapeutic support, there’s a real need to make sure they have access to a choice of a range of appropriate therapies delivered by appropriately qualified individuals,” she said.
